Nokea
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
- A. Decreased deep tendon reflexes.
- B. Cool skin temperature.
- C. Rapid pulse rate.
- D. Tingling in the toes.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a sign of hypermagnesemia.
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A primigravid client delivered vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?
- A. By discharge, the family will bond with the neonate.
- B. The client will demonstrate self-care and infant care by the end of the shift.
- C. The client will state instructions for discharge during the first postpartum day.
- D. By the end of the shift, the client will describe a safe home environment.
Correct Answer: B
Rationale: The highest priority in the immediate postpartum period is ensuring the client can perform self-care and infant care, as this promotes safety and independence, which are critical for recovery and newborn care.
A primiparous client post-cesarean asks about preventing constipation. The nurse should recommend:
- A. Limiting fluid intake to avoid bladder distention.
- B. Eating a low-fiber diet for the first week.
- C. Increasing intake of fruits and whole grains.
- D. Taking a laxative daily for 2 weeks.
Correct Answer: C
Rationale: Fruits and whole grains provide fiber, promoting regular bowel movements and preventing constipation.
While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
- A. Tell the client to leave the boyfriend immediately.
- B. Ask the client when she last felt the baby move.
- C. Refer the client to a social worker for possible options.
- D. Report the incident to the unit nursing supervisor.
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.
A client asks about the benefits of male condoms. Which of the following would the nurse include?
- A. They are 100% effective in preventing pregnancy.
- B. They provide some protection against STIs.
- C. They can be reused if undamaged.
- D. They require a prescription.
Correct Answer: B
Rationale: Male condoms provide some protection against STIs, which is a key benefit. They are not 100% effective, cannot be reused, and do not require a prescription.
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?
- A. It's of no concern because it is such a small amount.
- B. The cause is usually related to swallowing blood during the delivery.
- C. Sometimes baby girls have this from hormones received from the mother.
- D. This vaginal spotting is caused by hemorrhagic disease of the newborn.
Correct Answer: C
Rationale: Pseudo-menstruation in female newborns is due to maternal hormone withdrawal.