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. Tachypnea.
- B. Hyporeflexia.
- C. Agitation.
- D. Polyuria.
Correct Answer: B
Rationale: Hyporeflexia indicates magnesium sulfate toxicity, a serious adverse effect requiring immediate reporting to prevent respiratory or cardiac issues.
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A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test.
Which of the following statements should the nurse make?
- A. You will not be able to eat or drink anything for several hours prior to the test.
- B. You will receive medication through an IV to initiate contractions.
- C. You will be required to lie flat on your back for the duration of the test.
- D. You will press the provided button when you feel the baby move during the test.
Correct Answer: D
Rationale: Pressing a button when the baby moves during a nonstress test records fetal activity, assessing well-being without inducing contractions.
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 hours.
- B. Give the newborn 30 ml of distilled water after each feeding.
- C. Monitor the newborn's blood glucose level every hour.
- D. Apply a water-based ointment to the newborn's skin every 6 hours.
Correct Answer: A
Rationale: Repositioning the newborn every 2 hours ensures even exposure to phototherapy light, preventing skin breakdown and effectively reducing bilirubin levels.
A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
- A. Provide additional hydration by offering glucose water.
- B. Apply a water-based lotion to the newborn's skin every 4 hours.
- C. Remove the newborn from phototherapy every 2 hours for breastfeeding.
- D. Monitor the newborn's heart rate every 2 hours.
Correct Answer: C
Rationale: Removing the newborn for breastfeeding every 2 hours ensures nutrition and bonding without significantly disrupting phototherapy.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Early ambulation prevents blood stasis, a key measure to reduce thrombophlebitis risk post-cesarean.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.