Nokea
The nurse is caring for a client with severe preeclampsia. What finding would indicate magnesium sulfate toxicity?
- A. Increased deep tendon reflexes.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 160/110 mmHg.
Correct Answer: B
Rationale: Respiratory depression is a key sign of magnesium sulfate toxicity, requiring immediate action.
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A client at 12 weeks' gestation asks about managing constipation during pregnancy. What is the nurse's best advice?
- A. Take a laxative daily.
- B. Increase fiber intake and fluids.
- C. Avoid physical activity.
- D. Limit vegetable consumption.
Correct Answer: B
Rationale: Increasing dietary fiber and fluids helps relieve constipation, which is common during pregnancy.
The nurse is describing different types of abruptio placenta to a group of students explaining that the incomplete abruptio placenta is
- A. There is massive bleeding in the presence of almost total separation
- B. Separation beginning at the periphery of the placenta
- C. The placenta separates centrally and there can be concealed bleeding
- D. Blood passes between the fetal membrane of the uterine wall and is skipped vaginally
Correct Answer: B
Rationale: In incomplete abruptio placenta, the separation begins at the periphery of the placenta. This results in partial detachment of the placenta from the uterine wall, rather than almost total separation as seen in complete abruptio placenta. This type of abruptio placenta may present with vaginal bleeding depending on the extent of separation and may lead to various degrees of maternal and fetal compromise.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.
The nurse is caring for a client in the second stage of labor. What finding indicates readiness for delivery?
- A. Fetal head is at station 0.
- B. Contractions every 3–5 minutes.
- C. Fetal head is crowning.
- D. Cervix is dilated to 8 cm.
Correct Answer: C
Rationale: Crowning indicates that the fetal head is visible at the vaginal opening, signifying readiness for delivery.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
- A. Hemoglobin of 11 g/dL (110 mmol/L)
- B. Fetal heart rate of 180 beats/minute
- C. Maternal pulse rate of 85 beats/minute
- D. White blood cell count of 12,000 mm3 (12.0 × 109/L)
Correct Answer: B
Rationale: A fetal heart rate of 180 bpm may indicate fetal distress and warrants immediate HCP notification.