Nokea
After administering hydralazine(Apresoline) 5 mg intravenously as ordered for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:
- A. Tachycardia.
- B. Bradypnea.
- C. Polyuria.
- D. Dysphagia.
Correct Answer: A
Rationale: Tachycardia is a potential side effect of hydralazine.
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After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?
- A. "I may develop hyperthyroidism because of my high blood pressure."
- B. "I need close monitoring because I may have a small-for-gestational-age infant."
- C. "It's possible that I will have excess amniotic fluid and may need a cesarean section."
- D. "I may develop placenta accreta, so I need to keep my clinic appointments."
Correct Answer: B
Rationale: Chronic hypertension increases the risk of having a small-for-gestational-age infant.
The nurse is teaching a multiparous breast-feeding client about managing mastitis. Which instruction is most appropriate?
- A. Stop breast-feeding until symptoms resolve.
- B. Apply warm compresses before feeding.
- C. Take antibiotics only if fever persists.
- D. Massage the breast vigorously during feeding.
Correct Answer: B
Rationale: Warm compresses before feeding promote milk flow and relieve duct blockage, aiding mastitis resolution.
A nurse is counseling a client about the contraceptive sponge. Which of the following client statements indicates a need for further teaching?
- A. The sponge can be inserted just before intercourse.
- B. The sponge contains spermicide.
- C. The sponge is reusable if cleaned properly.
- D. The sponge should be left in place for at least 6 hours after intercourse.
Correct Answer: C
Rationale: The contraceptive sponge is a single-use device and cannot be reused, even if cleaned, indicating a need for further teaching. The other statements are correct.
In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior(LOA) position?
- A. Near the symphysis pubis.
- B. Two inches above the umbilicus.
- C. Below the umbilicus on the left side.
- D. At the level of the umbilicus.
Correct Answer: C
Rationale: The transducer should be placed below the umbilicus on the left side for LOA position.
A breast-feeding primiparous client who delivered 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake?
- A. Six to eight wet diapers by the fifth day.
- B. Three to four transitional stools on the fourth day.
- C. Ability to fall asleep easily after feeding on the first day.
- D. Regain of lost birth weight by the third day.
Correct Answer: A
Rationale: Six to eight wet diapers by the fifth day indicate adequate milk intake.