Nokea
Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the physician orders a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/minute.
- B. Patellar reflex of +2.
- C. Blood pressure of 160/88 mm Hg.
- D. Urinary output exceeding intake.
Correct Answer: A
Rationale: A respiratory rate of 12 breaths/minute indicates potential magnesium sulfate toxicity.
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A client delivered 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client?
- A. I will wear a sports bra or a well fitting bra for several days.
- B. When showering, I'll direct water onto my shoulders.
- C. I will only use only water to clean my nipples.
- D. I will use a breast pump to remove any milk that may appear.
Correct Answer: D
Rationale: Using a breast pump can stimulate milk production, which is counterproductive for bottle-feeding mothers.
After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia, the nurse determines that the client understands the instruction when she says that hyperglycemia may be manifested by which of the following?
- A. Dehydration.
- B. Pallor.
- C. Sweating.
- D. Nervousness.
Correct Answer: A
Rationale: Dehydration is a symptom of hyperglycemia.
A nurse is teaching a client about the use of spermicides. Which of the following client statements indicates understanding?
- A. Spermicide should be applied 10-30 minutes before intercourse.
- B. Spermicide is effective for up to 24 hours.
- C. Spermicide provides protection against STIs.
- D. Spermicide is most effective when used alone.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is effective for about 1 hour, does not protect against STIs, and is most effective with barrier methods.
The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. Which of the following would the nurse expect the physician to order?
- A. Frequent assessments of cervical dilation.
- B. Intravenous oxytocin administration.
- C. Vaginal culture for Neisseria gonorrhoeae.
- D. Sonogram for amniotic fluid volume index.
Correct Answer: C
Rationale: Vaginal cultures help identify infections after membrane rupture.
The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?
- A. A slight drop followed by a rise in basal body temperature.
- B. A change in cervical mucus to thin, clear, and stretchy.
- C. The onset of mittelschmerz, or midcycle pelvic pain.
- D. The presence of a thick, cloudy cervical mucus.
Correct Answer: A
Rationale: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.