Nokea
An obviously pregnant woman walks into the hospital's emergency department entrance shouting. 'Help me! Help me! My baby is coming! I'm so afraid!' The nurse determines if delivery is indeed imminent, what action is most important for the nurse to take?
- A. Determine the gestational age of fetus
- B. Assess the amount and color of the amniotic fluid
- C. Obtain peripheral IV access and begin administration of IV fluids
- D. Provide clear concise instructions in a calm, deliberate manner
Correct Answer: D
Rationale: Providing clear instructions (D) helps manage the situation calmly and effectively.
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The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client?
- A. Administration of Pitocin
- B. Artificial rupture of the membrane
- C. Amnioinfusion for the baby
- D. Administration of antibiotics
Correct Answer: D
Rationale: Antibiotics (D) are administered to GBS+ mothers to prevent neonatal infection.
Which step of the nursing process is being used when the nurse decides whether an ethical dilemma exists?
- A. Analysis
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Deciding whether an ethical dilemma exists involves analyzing collected data to determine if conflicting values or principles are present.
A pregnant patient's diet may not meet her need for folate. Which food choice is an excellent source of this nutrient?
- A. Chicken
- B. Cheese
- C. Potatoes
- D. Green leafy vegetables
Correct Answer: D
Rationale: The correct answer is D: Green leafy vegetables. Green leafy vegetables such as spinach, kale, and broccoli are excellent sources of folate, a crucial nutrient for pregnant women to prevent neural tube defects in the fetus. These vegetables are rich in natural folate, making them an ideal choice for meeting the increased folate requirements during pregnancy. Chicken (A), cheese (B), and potatoes (C) do not contain as high levels of folate as green leafy vegetables, making them less optimal choices for ensuring adequate intake of this essential nutrient during pregnancy.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
- A. Provide oral hydration
- B. Have a complete blood count (CBC) drawn
- C. Obtain a specimen for urine analysis
- D. Place the client on strict bedrest
Correct Answer: C
Rationale: Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.