Nokea
A woman is being treated for preterm labor with magnesium
- A. The nurse is concerned that the patient is experiencing early drug toxicity. Which assessment finding by the nurse indicates early toxicity?
- B. Patellar reflexes are weak and absent
- C. RR 16
- D. Fetal HR 120
Correct Answer: E
Rationale: The correct assessment finding that indicates early toxicity related to magnesium sulfate administration is the patient complaining of feeling flushed and warm. These symptoms could indicate that the patient is experiencing magnesium toxicity, which can lead to vasodilation and hypotension. Other signs of magnesium toxicity include decreased deep tendon reflexes, respiratory depression, and loss of consciousness. It's essential for the nurse to recognize these early signs of toxicity and intervene promptly to prevent further complications.
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A 35-year-old patient comes to the clinic 2 days after a tubal ligation. She complains of abdominal pain and swelling and redness at the surgical incision. What does the nurse know is a common complication of this procedure?
- A. Ileus
- B. Liver enlargement
- C. Constipation
- D. Infection
Correct Answer: D
Rationale: Infection is a common complication after tubal ligation, indicated by redness and swelling at the surgical site. Choice A is incorrect as ileus is a bowel obstruction, not typically a complication of tubal ligation. Choice B, liver enlargement, is unrelated to tubal ligation. Choice C, constipation, may be a side effect but is not a primary concern after this procedure.
Which of the following interpretations of this finding should the nurse make?
- A. The presenting part is 1 cm above the ischial spines.
- B. The presenting part is 1 cm below the ischial spines.
- C. The cervix is 1 cm dilated.
- D. The cervix is effaced 1 cm.
Correct Answer: A
Rationale: The finding of "station -1" indicates that the presenting part of the baby is 1 cm above the ischial spines in the mother's pelvis. Station is a measurement used in obstetrics to describe the position of the presenting part of the fetus in relation to the ischial spines of the mother's pelvis during labor. Stations are measured in centimeters and range from -5 (highest) to +5 (lowest). In this case, a station of -1 means the baby's presenting part is 1 cm above the ischial spines. This information helps healthcare providers assess the progress of labor and determine the positioning of the baby during delivery.
Which data in the patient's history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?
- A. Previous depressive episode
- B. Unexpected operative birth
- C. Ambivalence during the first trimester
- D. Second pregnancy in a 3-year period
Correct Answer: A
Rationale: A previous history of depression is a significant risk factor for postpartum depression. Women who have experienced a depressive episode in the past are more likely to develop postpartum depression compared to those without such a history. Recognizing this pertinent data in the patient's history can help the nurse identify individuals at higher risk for postpartum depression and provide appropriate support and intervention. The other options mentioned (B. Unexpected operative birth, C. Ambivalence during the first trimester, D. Second pregnancy in a 3-year period) may also contribute to emotional distress but are not as directly linked to postpartum depression as a previous depressive episode.
How should a nurse educate a mother about kangaroo care for her preterm infant?
- A. Encourage frequent visits to the NICU
- B. Educate about skin-to-skin contact benefits
- C. Explain the importance of bonding
- D. Teach the mother about safe handling of the newborn
Correct Answer: B
Rationale: Kangaroo care promotes bonding and regulates temperature for preterm infants.
A woman delivered a baby 9lbs 10oz 1 hour ago. When you
arrive to perform a 15-minute assessment she tells you that she feels
all wet underneath. You discover that both pads are completely
saturated and that she’s lying in a 6-inch diameter of blood. What
does nurse do first
- A. Assess the fundus for firmness
- B. Change the patient's pads
- C. Notify the provider
- D. Document the findings
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse to take is to assess the source of the woman's feeling of wetness underneath her. This could indicate a significant amount of postpartum bleeding, also known as hemorrhage. It is crucial to determine if she is experiencing excessive bleeding as this can be life-threatening if not addressed promptly. By identifying the source of the wetness, the nurse can assess the situation and take appropriate actions to address any potential complications. Once the severity of bleeding is determined, further assessments and interventions can be initiated accordingly.