Nokea
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation. Based on the client's symptoms, the nurse determines additional assessments are needed. Select the 4 assessments the nurse should perform.
- A. Fingerstick hemoglobin.
- B. Urine for protein.
- C. Perineal assessment.
- D. Vision test.
- E. Skin turgor.
- F. Deep tendon reflexes.
- G. Lung sounds.
Correct Answer: B,D,F,G
Rationale: Urine protein, vision test, deep tendon reflexes, and lung sounds assess preeclampsia indicators like proteinuria, visual disturbances, CNS irritability, and pulmonary edema.
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Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mm Hg and her heart rate is 130 beats/minute. Which action should the nurse implement first?
- A. Obtain a blood sample for complete blood count.
- B. Infuse 1,000 mL normal saline using a large bore intravenous (IV) catheter.
- C. Palpate the abdomen for contractions.
- D. Tilt the backboard sideways to displace the uterus laterally.
Correct Answer: D
Rationale: Tilting the backboard relieves uterine compression on the inferior vena cava, addressing supine hypotension syndrome, which is critical to improve maternal blood pressure and fetal perfusion.
A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Shallow and irregular respirations.
- B. Flaring of the nares.
- C. Abdominal breathing with synchronous chest movement.
- D. Respiratory rate of 50 breaths per minute.
Correct Answer: B
Rationale: Nasal flaring indicates increased breathing effort, a sign of respiratory distress in newborns, unlike normal respiratory patterns.
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Give zidovudine 6 to 12 hours after birth.
- C. Administer antibiotics for 7 to 10 days.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: B
Rationale: Zidovudine within 6-12 hours reduces HIV transmission risk in newborns of HIV-positive mothers, unlike breastfeeding, which is contraindicated, or antibiotics and delayed bathing, which are irrelevant.
A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75-second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20-second duration. Which intervention should the nurse implement?
- A. Notify the nursery about the client's response.
- B. Restart oxytocin infusion rate per protocol.
- C. Stop oxygen per cannula.
- D. Check for clonus in both feet.
Correct Answer: B
Rationale: Restarting oxytocin per protocol resumes labor induction safely after uterine rest, ensuring continued progress without hyperstimulation.