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As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do first?
- A. Insert an airway to improve oxygenation.
- B. Note the time when the seizure begins and ends.
- C. Call for immediate assistance.
- D. Turn the client to her left side.
Correct Answer: D
Rationale: Turning the client to her left side helps maintain airway patency and prevents aspiration.
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An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa(Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?
- A. "I need to reduce my caloric intake to 1,200 calories a day."
- B. "A regular diet is recommended during pregnancy."
- C. "I should eat more frequent meals if I get heartburn."
- D. "I need to consume more fluids and fiber each day."
Correct Answer: A
Rationale: Reducing caloric intake too much can be harmful during pregnancy.
A full-term neonate is admitted to the normal newborn nursery. The nurse notes a Moro reflex. What should the nurse do next?
- A. Call a code.
- B. Identify this reflex as a normal finding.
- C. Place the neonate on seizure precautions.
- D. Start supplemental oxygen.
Correct Answer: B
Rationale: The Moro reflex is a normal finding in full-term neonates, indicating a healthy neurological response.
A newborn weighing 6½ lb is to be given naloxone hydrochloride (Narcan) due to respiratory depression caused by a narcotic administered to the mother shortly before delivery. The dosage is 0.01 mg/kg, administered into the umbilical vein. The vial is labeled 0.4 mg/mL.. How many milligrams would the newborn receive? Round to two decimals.
Correct Answer: 0.03 mg
Rationale: The neonate weighs 6.5 lb (2.95 kg). The dose is 0.01 mg/kg, so 0.01 mg/kg × 2.95 kg = 0.0295 mg, rounded to 0.03 mg.
When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?
- A. Return visit to the prenatal clinic in approximately 4 weeks.
- B. Decreased edema after 1 week of a low-protein, low-fiber diet.
- C. Bed rest on the left side during the day, with bathroom privileges.
- D. Immediate reporting of adverse reactions to magnesium sulfate therapy.
Correct Answer: C
Rationale: Bed rest on the left side enhances placental perfusion and reduces blood pressure.
Carboprost (Hemabate) was injected into the uterus of a client to treat uterine atony during a cesarean section. In preparing to care for this client postpartum, the nurse should assess the client for which of the following common adverse effects of the medication?
- A. Vertigo and confusion.
- B. Nausea and diarrhea.
- C. Restlessness and increased vaginal bleeding.
- D. Headache and hypertension.
Correct Answer: B
Rationale: Carboprost commonly causes nausea and diarrhea as side effects.