Nokea
A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would lead the nurse to suspect that the client is having an adverse effect associated with this drug?
- A. Gastrointestinal bleeding
- B. Sweating
- C. Tachycardia
- D. Blurred vision
Correct Answer: C
Rationale: Hydralazine, a vasodilator, can cause reflex tachycardia as blood pressure drops, increasing cardiac strain. Gastrointestinal bleeding, sweating, and blurred vision (a preeclampsia symptom) are not typical adverse effects.
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Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?
- A. Ferrous sulfate
- B. Potassium chloride
- C. Calcium carbonate
- D. Calcium gluconate
Correct Answer: D
Rationale: Calcium gluconate reverses magnesium toxicity (e.g., respiratory depression), a risk with magnesium sulfate used for preeclampsia. Ferrous sulfate treats anemia, potassium chloride corrects hypokalemia, and calcium carbonate is an antacid, none addressing toxicity.
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating
- A. Hemodilution of pregnancy
- B. A multiple gestation pregnancy
- C. Greater-than-expected weight gain
- D. Iron-deficiency anemia
Correct Answer: A
Rationale: Hemodilution of pregnancy occurs as plasma volume increases more than red blood cell mass, lowering hemoglobin to 10.5-14 g/dL in the second trimester, which includes 11 g/dL. Multiple gestation may raise hemoglobin, weight gain doesn't affect it, and iron-deficiency anemia typically shows lower hemoglobin with symptoms like fatigue.
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?
- A. Hemorrhage
- B. Edema
- C. Infection
- D. Jaundice
Correct Answer: A
Rationale: A ruptured ectopic pregnancy causes internal bleeding, leading to hypovolemic shock, making hemorrhage the priority assessment. Edema, infection, or jaundice may occur later but are less urgent than life-threatening bleeding.
During a prenatal visit, a pregnant woman says, 'I know the amniotic fluid is important, but can you tell me more about it?' When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include?
- A. This fluid acts as a cushion to help protect your baby from injury.
- B. The amount of fluid remains fairly constant throughout the pregnancy.
- C. The fluid is mostly protein to provide nourishment to your baby.
- D. This fluid acts as a transport mechanism for oxygen and nutrients.
Correct Answer: A
Rationale: Amniotic fluid cushions the fetus against injury, aiding movement and growth. Its volume varies (peaks at term), is mostly water (not protein), and doesn't transport oxygen or nutrients, which the placenta handles.
A client's last menstrual period was April 11. Using Naegele's rule, her estimated date of birth (EDB) would be:
- A. 24-Feb
- B. 18-Jan
- C. 25-Jan
- D. 18-Feb
Correct Answer: B
Rationale: Nägele's rule: April 11, 2023 + 1 year = April 11, 2024; minus 3 months = January 11, 2024; plus 7 days = January 18, 2024. Other options incorrectly adjust months or days.