Nokea
The nurse is assessing a client at 36 weeks' gestation who reports swelling in the hands and face. What is the priority nursing action?
- A. Check the client’s blood pressure.
- B. Reassure the client that swelling is normal.
- C. Encourage the client to reduce salt intake.
- D. Evaluate the fetal heart rate.
Correct Answer: A
Rationale: Swelling in the hands and face may indicate preeclampsia, requiring immediate blood pressure assessment.
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What is considered the first day of the menstrual cycle?
- A. day of ovulation
- B. first day of menstrual bleeding
- C. last day of menstrual bleeding
- D. when the corpus luteum forms
Correct Answer: B
Rationale:
The nurse is planning to admit a pregnant client who is obese. Which potential client needs should the nurse anticipate?
- A. Routine administration of subcutaneous heparin may be prescribed.
- B. Bed rest as a necessary preventive measure may be prescribed.
- C. An overbed lift may be necessary if the client requires a cesarean section.
- D. Thromboembolism stockings or sequential compression devices may be prescribed.
Correct Answer: D
Rationale: Obese clients may need thromboembolism prevention and specialized equipment for safe cesarean handling.
A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36C and a persisting oxygen saturation of <87%. The nurse interprets these findings as:
- A. Cardiac distress
- B. Respiratory Alkalosis
- C. Bronchial pneumonia
- D. Respiratory Distress
Correct Answer: D
Rationale: The newborn's presentation with a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, and persisting low oxygen saturation (<87%) are indicative of respiratory distress. These signs suggest that the newborn is having difficulty breathing and may not be getting enough oxygen into their system. Respiratory distress in newborns is a serious condition that requires immediate attention and intervention to support breathing and oxygenation. It is crucial for healthcare providers to recognize and address respiratory distress promptly to prevent further complications.
During a trauma-informed gynecologic examination, what principle emphasizes the importance of involving the patient in decision making about their health care?
- A. respecting autonomy and empowerment
- B. trauma-sensitive language and communication
- C. providing information and explanation
- D. avoiding triggering situations
Correct Answer: A
Rationale:
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
- A. Blood pressure 142/92 mm Hg
- B. Urine output 100 mL in hr.
- C. Pulse 58/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: Methylergonovine is a medication used to help contract the uterus and control postpartum hemorrhage. One of its side effects is vasoconstriction, which can lead to increased blood pressure. The client's blood pressure of 142/92 mm Hg is elevated, and administering methylergonovine could further increase the blood pressure, potentially causing harm to the client. It is important to withhold the medication in this situation to prevent worsening of hypertension. The other assessment findings are within normal ranges and do not contraindicate the administration of methylergonovine.