Nokea
A woman is being treated for preterm labor with magnesium
- A. The nurse is concerned that the patient is experiencing early drug toxicity. Which assessment finding by the nurse indicates early toxicity?
- B. Patellar reflexes are weak and absent
- C. RR 16
- D. Fetal HR 120
Correct Answer: E
Rationale: The correct assessment finding that indicates early toxicity related to magnesium sulfate administration is the patient complaining of feeling flushed and warm. These symptoms could indicate that the patient is experiencing magnesium toxicity, which can lead to vasodilation and hypotension. Other signs of magnesium toxicity include decreased deep tendon reflexes, respiratory depression, and loss of consciousness. It's essential for the nurse to recognize these early signs of toxicity and intervene promptly to prevent further complications.
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A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.
The nurse is assessing a client with suspected ectopic pregnancy. What is the most common symptom?
- A. Bright red vaginal bleeding.
- B. Severe lower abdominal pain.
- C. Increased fetal movement.
- D. Painless vaginal spotting.
Correct Answer: B
Rationale: Severe lower abdominal pain, often on one side, is a hallmark symptom of ectopic pregnancy.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
A nurse in a woman's health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client's risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: Chlamydia infection is a significant risk factor for developing pelvic inflammatory disease (PID). PID is commonly caused by untreated or inadequately treated sexually transmitted infections such as chlamydia and gonorrhea. When these infections ascend through the reproductive organs, they can lead to inflammation, scarring, and damage to the reproductive structures, resulting in PID. It is crucial for healthcare providers to identify and treat chlamydia infections promptly to prevent complications like PID. Recurrent cystitis (choice A), frequent alcohol use (choice B), and use of oral contraceptives (choice C) do not directly increase the risk for PID as compared to a sexually transmitted infection like chlamydia.
On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.