Nokea
Fifteen minutes after a client experiences an eclamptic seizure, the nurse should assess the client for which of the following?
- A. Polyuria.
- B. Facial flushing.
- C. Hypotension.
- D. Uterine contractions.
Correct Answer: D
Rationale: Uterine contractions should be assessed post-seizure to evaluate labor status.
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Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
- A. A client at 13 weeks' gestation experiencing nausea and vomiting three times a day with +1 ketones in her urine.
- B. A client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day.
- C. A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.
- D. A primigravida at 17 weeks' gestation complaining of not feeling fetal movement at this point in her pregnancy.
Correct Answer: C
Rationale: Epigastric pain in a preeclamptic client can indicate impending eclampsia.
A primiparous client bottle-feeding her neonate asks about sterilizing bottles. The nurse should instruct the client to:
- A. Boil bottles for 10 minutes after each use.
- B. Use a dishwasher with a sanitize cycle.
- C. Soak bottles in bleach solution daily.
- D. Wash bottles with hot soapy water only.
Correct Answer: B
Rationale: A dishwasher with a sanitize cycle effectively sterilizes bottles, ensuring safety for the neonate.
A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
- A. Discuss how they will cope with twin infants at home.
- B. Participate in care of the twins as much as possible.
- C. Take turns providing 24-hour observation of the twins.
- D. Identify complications that may occur as the twins develop.
Correct Answer: B
Rationale: Parental participation in twin care during hospitalization promotes bonding, confidence, and skill development. Discussing coping, 24-hour observation, or identifying complications are less immediate or unrealistic.
The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks very little English and delivered a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following?
- A. High-fiber foods and adequate fluids.
- B. Low-calorie foods to promote weight loss.
- C. High-protein foods only.
- D. Caffeinated beverages to maintain energy.
Correct Answer: A
Rationale: High-fiber foods and adequate fluids promote bowel function and hydration, which are essential for postpartum recovery.
A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching?
- A. My fallopian tubes will be tied off through a small abdominal incision.
- B. Reversal of a tubal ligation is easily done, with a subsequent pregnancy rate of 80%.
- C. The tubal ligation will decrease my risk of getting ovarian cancer.
- D. The tubal ligation will cause me to go through menopause earlier than usual.
Correct Answer: A
Rationale: Tubal ligation involves blocking or tying the fallopian tubes, often through a small abdominal incision. Reversal is complex with lower success rates, it does not significantly reduce ovarian cancer risk, and it does not affect menopause timing.