Nokea
The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)
- A. Explaining procedures.
- B. Treating nausea.
- C. Ensuring side rails are padded.
- D. Assisting with breast pumping.
- E. Evaluating blood pressure frequently.
- F. Evaluating for headache.
- G. Assessing deep tendon reflexes.
Correct Answer: C,E,G,H
Rationale: Padded side rails, frequent blood pressure checks, reflex assessment, and minimizing visitors stabilize the client by preventing injury, monitoring hypertension, and reducing seizure triggers.
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A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
- A. Intensity of pain with contraction.
- B. Fetal heart rate.
- C. Temperature, pulse, and respirations.
- D. Deep tendon reflexes and clonus.
Correct Answer: D
Rationale: Assessing deep tendon reflexes and clonus detects CNS irritability, critical for identifying severe preeclampsia and eclampsia risk.
A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75-second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20-second duration. Which intervention should the nurse implement?
- A. Notify the nursery about the client's response.
- B. Restart oxytocin infusion rate per protocol.
- C. Stop oxygen per cannula.
- D. Check for clonus in both feet.
Correct Answer: B
Rationale: Restarting oxytocin per protocol resumes labor induction safely after uterine rest, ensuring continued progress without hyperstimulation.
Which action is most important for the nurse to implement?
- A. Increase IV infusion rate.
- B. Assess the vital signs.
- C. Massage the fundus.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, critical for controlling postpartum hemorrhage and stabilizing the patient.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.
History and Physical:
Nurses' Notes:
Vital Signs
The neonate was born vaginally at 0130 to a 32-year-old gravida 3, para 3, abortion 0 (G3P3A0) mother. The neonate was born at 39 weeks gestation. The mother had an uncomplicated pregnancy and delivery.
The nurse evaluates the data presented. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Potential Conditions: Altered respiratory function, Hypoglycemia, Thermoregulation, Sepsis, Hyperbilirubinemia
- B. Actions: Provide manual breaths with a bag-valve mask (BVM), Give dextrose solution orally, Administer intravenous (IV) antibiotics, Place the neonate under a radiant warmer, Perform a heel stick for blood glucose testing
- C. Parameters: Respiratory rate, Temperature, Blood glucose levels, Oxygen saturation, Bilirubin levels
Correct Answer: B,E,C
Rationale: Hypoglycemia is likely due to jitteriness and low temperature; oral dextrose and heel stick glucose testing address it, while monitoring glucose levels and temperature tracks progress.