Nokea
The nurse is caring for a client with preeclampsia. What is the primary goal of magnesium sulfate therapy?
- A. To reduce blood pressure.
- B. To prevent seizures.
- C. To improve fetal circulation.
- D. To treat headaches.
Correct Answer: B
Rationale: Magnesium sulfate is administered in preeclampsia primarily to prevent eclampsia-related seizures.
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The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
A delivering patient presses the call light and reports that her water just broke the nurse first action should be:
- A. Check the fetal heart tone
- B. Call physician
- C. Change bed linen
- D. Encourage mother to go for a walk
Correct Answer: A
Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.
The nurse is performing Leopold's maneuvers on a pregnant client. What is the primary purpose?
- A. Assess fetal heart tones.
- B. Determine fetal position.
- C. Evaluate amniotic fluid volume.
- D. Check for uterine contractions.
Correct Answer: B
Rationale: Leopold's maneuvers help determine the position and presentation of the fetus within the uterus.
The nurse is conducting a prenatal class about amniotic fluid. Which characteristics should be included in the teaching?
- A. Allows for fetal movement.
- B. Surrounds, cushions, and protects the fetus.
- C. Maintains the body temperature of the fetus.
- D. Can be used to measure fetal kidney function.
Correct Answer: B
Rationale: Amniotic fluid serves multiple functions, including cushioning the fetus, temperature regulation, and monitoring fetal kidney health.