Nokea
The nurse is administering intravenous magnesium sulfate as ordered for a client at 34 weeks' gestation with severe preeclampsia. Which of the following are desired outcomes of this therapy? Select all that apply.
- A. T 98, P 72, R 14.
- B. Urinary output<30 mL/hr.
- C. HR 120 BPM.
- D. Fetal heart rate with late decelerations.
- E. BP of <140/90.
- F. DTR's 2+.
- G. Magnesium level= 5.6 mg/dL.
Correct Answer: A,E,F,G
Rationale: Desired outcomes include stable vital signs, absence of late decelerations, and controlled deep tendon reflexes.
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A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should first:
- A. Consult with health care provider to obtain a chest x-ray.
- B. Reposition the neonate and then assess if the grunting and cyanosis resolve.
- C. Begin oxygen administration at 6-8 L via mask.
- D. Obtain a complete blood count to determine infection.
Correct Answer: A
Rationale: These symptoms suggest a serious condition like dextrocardia or pneumothorax, and consulting for a chest x-ray is the priority to confirm the diagnosis.
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
A nurse is teaching a client about the use of the vaginal contraceptive ring. Which of the following instructions should the nurse include?
- A. Insert a new ring daily.
- B. Leave the ring in place for 3 weeks, then remove for 1 week.
- C. Apply the ring to the vaginal wall.
- D. Replace the ring every 6 months.
Correct Answer: B
Rationale: The vaginal contraceptive ring is left in place for 3 weeks, then removed for 1 week to allow a withdrawal bleed. It is not inserted daily, applied to the vaginal wall (it sits in the vagina), or replaced every 6 months (it's monthly).
After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching?
- A. I'll burp him after 15 minutes of feeding him formula.
- B. After he takes one-half ounce of formula, I'll burp him.
- C. I'll burp him while he is in an upright position.
- D. I'll gently pat his back to get him to burp.
Correct Answer: B
Rationale: Burping after one-half ounce is too frequent and may disrupt feeding; burping every 1-2 ounces is more appropriate.