Nokea
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Strawberries
- B. Collard greens.
- C. Whole milk
- D. Yogurt
Correct Answer: A
Rationale: Strawberries provide a moderate amount of folic acid and are suitable given the client's dislike for green leafy vegetables and soy allergy.
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A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
- A. Estimated amount of fluid.
- B. Color and consistency of fluid.
- C. Time the membranes ruptured
- D. Any odor noted when membranes ruptured
Correct Answer: C
Rationale: The time of membrane rupture is critical to assess the risk of infection, which increases with prolonged rupture, especially in active labor.
The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
- A. Insert a Foley catheter with a urimeter to monitor hourly output
- B. Have calcium gluconate immediately available
- C. Provide a quiet environment with subdued lighting.
- D. Assess deep tendon reflexes (DTRS) every 4 hours.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause neuromuscular blockade, making calcium gluconate, the antidote, critical to have immediately available in case of toxicity signs like loss of deep tendon reflexes.
The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?
- A. Administer oxygen via facemask.
- B. Turn off the oxytocin infusion
- C. Assess cervical dilatation
- D. Change the client's position
Correct Answer: D
Rationale: Variable decelerations often result from umbilical cord compression. Changing the client's position, such as to a lateral or knee-chest position, is the first step to relieve this.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Prepare for a cesarean section
- B. Cover the lesion with a dressing
- C. Obtain blood cultures
- D. Administer penicillin.
Correct Answer: A
Rationale: Active herpes lesions pose a risk of neonatal herpes transmission during vaginal delivery. Preparing for a cesarean section is the priority to minimize this risk.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols
- B. Discontinue the methadone right away
- C. Sign up for group therapy sessions
- D. Start a prenatal care plan as soon as possible
Correct Answer: D
Rationale: Early prenatal care is critical for monitoring maternal and fetal health, managing opioid addiction with methadone under medical supervision, and addressing potential complications.