Nokea
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
- A. Call for immediate assistance.
- B. Turn the client to her side.
- C. Note the time when the seizure began.
- D. Maintain airway.
Correct Answer: A,D,B,C
Rationale: Call for help, ensure the airway is clear, turn the client to prevent aspiration, and document the seizure duration.
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A nurse is discussing sterilization with a male client. Which of the following client statements indicates understanding?
- A. A vasectomy requires a follow-up sperm count.
- B. A vasectomy prevents testosterone production.
- C. A vasectomy is effective immediately.
- D. A vasectomy is easily reversible.
Correct Answer: A
Rationale: A vasectomy requires a follow-up sperm count to confirm sterility. It does not affect testosterone production, is not effective immediately, and reversal is not always successful.
The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following?
- A. 7.5.
- B. 7.4.
- C. 7.3.
- D. 7.2.
Correct Answer: D
Rationale: A fetal scalp blood pH below 7.2 indicates acidosis, suggesting fetal hypoxia and the need for intervention. Values above 7.25 are typically reassuring, and 7.2–7.25 may warrant close monitoring.
The nurse is preparing to administer terbutaline(Brethine) to a multigravid client in preterm labor. Before administering this drug intravenously, the nurse should determine the results of the following?
- A. Hematocrit.
- B. Weight gain.
- C. Urinary output.
- D. Heart rate.
Correct Answer: D
Rationale: Heart rate should be monitored due to terbutaline's potential to cause tachycardia.
A client who is planning a pregnancy asks the nurse about the use of herbal supplements to enhance fertility. Which of the following responses by the nurse is most appropriate?
- A. Herbal supplements are safe and effective for enhancing fertility.
- B. Consult with your health care provider before taking any herbal supplements.
- C. Herbal supplements can replace prenatal vitamins during pregnancy.
- D. Most herbal supplements are regulated by the FDA for safety.
Correct Answer: B
Rationale: Herbal supplements can interact with medications or affect pregnancy, so consulting a healthcare provider is essential. They are not proven safe or effective for fertility, not a substitute for prenatal vitamins, and are not tightly regulated by the FDA.
The nurse in the labor and delivery area receives a telephone call from the emergency room announcing that a multigravid client in active labor is being transferred to the labor area. The client has been successful care, when the client arrives by stretcher, she says, 'I think the baby's coming ... Help!' The fetal skull is crowning. The nurse should obtain which of the following information first?
- A. Estimated date of delivery.
- B. Amniotic fluid status.
- C. Gravida and parity.
- D. Prenatal history.
Correct Answer: A
Rationale: With crowning, delivery is imminent, and confirming the estimated date of delivery ensures the neonate's gestational age is known for resuscitation planning. Fluid status, gravida/parity, and prenatal history are secondary.