Nokea
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
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A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
Pregnant Black people have more complications resulting from epigenetic changes caused by prolonged stress due to racism and discrimination. What complication could arise because of this history?
- A. postterm pregnancy
- B. preeclampsia
- C. liver disease
- D. cholestasis of pregnancy
Correct Answer: B
Rationale: Prolonged stress and systemic racism contribute to higher rates of preeclampsia in Black pregnant individuals.
A pregnant client tells the clinic nurse she wants to know the sex of her baby as soon as it can be determined. What factor allows this at 12 weeks' gestation?
- A. The appearance of the fetal external genitalia
- B. The beginning of differentiation in the fetal groin
- C. The fetal testes are descended into the scrotal sac
- D. The internal differences in males and females become apparent
Correct Answer: A
Rationale: By 12 weeks, the external genitalia are sufficiently developed for visual determination of the baby's sex.
The nurse is educating a client about postpartum care. What statement indicates the need for further teaching?
- A. I will call my doctor if I have a fever.
- B. It is normal to have heavy bleeding for two weeks.
- C. I will avoid lifting heavy objects.
- D. Breast tenderness is common when my milk comes in.
Correct Answer: B
Rationale: Heavy bleeding for two weeks is not normal and may indicate postpartum complications.
What is the priority nursing action for a newborn with a temperature of 35.5°C (95.9°F)?
- A. Place the newborn under a radiant warmer
- B. Administer warm IV fluids
- C. Swaddle the newborn in warm blankets
- D. Provide glucose supplementation
Correct Answer: A
Rationale: Placing the newborn under a radiant warmer helps raise body temperature and prevent complications.