Nokea
The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?
- A. Take the client’s vital signs
- B. Prepare examination equipment
- C. Give 2 liters oxygen per nasal cannula
- D. Assess the client’s response to the situation
Correct Answer: A
Rationale: Assessing the client’s VS should be completed first. Bleeding can cause hypotension. Although preparing examination equipment is important, the nurse should first focus on the client. Having oxygen available is important, but there is no indication that the client needs oxygen at this time. Assessing the client’s response is important, but assessment of physiological problems should occur first.
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The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategies might the nurse suggest that the client use with her child? Select all that apply.
- A. Read books about bringing home a new baby.
- B. Think of unique names for the new baby.
- C. Help pack a bag for bringing the new baby home.
- D. Explain how pregnancy occurred, if asked.
- E. Help the child buy presents for the new baby.
Correct Answer: A,B,C,E
Rationale: Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience. Engaging the child in activities such as buying presents for the new baby helps the child to feel a part of the experience. Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.
The nurse is assessing the client who is 34 weeks’ gestation. Place an X where the nurse should place the Doppler first to assess the FHR when the fetus is thought to be left occiput anterior (LOA).
Correct Answer:
Rationale: FHT are best heard in the lower left quadrant of the client’s abdomen when the fetus is LOA.
Which nursing instruction is most appropriate regarding the relief of itchy skin during pregnancy?
- A. Take a hot bath daily.
- B. Increase fluid intake.
- C. Add a daily vitamin C tablet to the diet.
- D. Take diphenhydramine (Benadryl) twice per day.
Correct Answer: B
Rationale: Increasing fluid intake hydrates the skin, reducing itchiness, while hot baths or antihistamines may worsen symptoms or require medical approval.
Which response by the nurse is most appropriate?
- A. A weight gain of about 10 pounds is recommended during pregnancy.
- B. Your weight gain depends on the amount of food that you eat.
- C. It's normal for adolescent girls to be worried about weight gain.
- D. You're average weight gain during pregnancy is between 25 and 35 pounds.
Correct Answer: D
Rationale: The average weight gain of 25-35 pounds is appropriate for a teenager with normal prepregnancy weight, addressing her concerns.