Nokea
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Polyuria
- B. Hyporeflexia
- C. Agitation
- D. Tachypnea
Correct Answer: B
Rationale: Hyporeflexia is an early sign of magnesium toxicity, indicating excessive neuromuscular blockade, requiring immediate reporting.
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A nurse is reinforcing discharge teaching about home safety with a client who is postpartum.
In which of the following positions should the nurse instruct the client to place their newborn in the crib?
- A. Right lateral
- B. Supine
- C. Prone
- D. Left lateral
Correct Answer: B
Rationale: The supine position reduces the risk of sudden infant death syndrome (SIDS) by keeping the airway open.
A charge nurse is discussing risk factors for postpartum hemorrhage with a newly licensed nurse.
Which of the following conditions should the nurse include as a risk factor?
- A. Urinary tract infection
- B. Breech presentation
- C. Oligohydramnios
- D. Retained placental fragments
Correct Answer: D
Rationale: Retained placental fragments prevent effective uterine contraction, leading to postpartum hemorrhage.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is planning to administer Rho(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
- A. Administer the medication into the client's abdomen.
- B. Administer the medication within 72 h after birth
- C. Verify that the newborn is Rh-negative
- D. Verify that the client's Coombs test is positive
Correct Answer: B
Rationale: Rho(D) immune globulin should be given within 72 hours after delivery to prevent Rh isoimmunization in an Rh-negative mother with an Rh-positive newborn.
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Give a bolus of lactated Ringer's
- B. Assist the client to empty her bladder.
- C. Place the client in knee chest position.
- D. Administer methylergonovine IM.
Correct Answer: A
Rationale: A bolus of lactated Ringer's increases intravascular volume, stabilizing blood pressure caused by epidural-induced vasodilation.