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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The nurse is educating a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions relieved by rest.
- B. Contractions felt only in the abdomen.
- C. Contractions that increase in intensity and cause cervical changes.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by contractions that progressively increase in intensity and result in cervical dilation and effacement.
What is the recommended position for a laboring mother with variable decelerations?
- A. Position the mother in a supine position
- B. Encourage the mother to change positions frequently
- C. Advise using a peanut ball to widen the pelvis
- D. Position the mother in a side-lying position
Correct Answer: D
Rationale: Side-lying reduces pressure on the umbilical cord, improving fetal oxygenation.
A 30-year-old woman is considering the use of emergency contraception. Which of the following is true about its use?
- A. It is most effective when used within 72 hours after unprotected sex.
- B. It should be used at least 5 days after unprotected sex to be effective.
- C. It prevents implantation of a fertilized egg into the uterine wall.
- D. It requires a prescription from a healthcare provider.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected sex. Choice B is incorrect as it is not as effective after 5 days. Choice C is incorrect because emergency contraception works primarily by preventing ovulation, not by preventing implantation. Choice D is incorrect because most emergency contraception methods are available over the counter.
The nurse is caring for a client in the second stage of labor. What finding indicates that birth is imminent?
- A. Cervix is fully dilated.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 140 beats/minute.
- D. Crowning is observed.
Correct Answer: D
Rationale: Crowning, or the appearance of the fetal head at the vaginal opening, indicates that birth is imminent.
What is the second stage of pathophysiology in an on anticoagulant therapy due to a deep vein throm- amniotic fluid embolism characterized by? bosis, which occurred after giving birth. Which of
- A. Hemorrhage the following instructions should the nurse include?
- B. Hypoxia
- C. Take an herbal supplement such as St. John's wort
- D. Capillary damage to help increase the effect of the anticoagulant.
Correct Answer: A
Rationale: The second stage of pathophysiology in an amniotic fluid embolism characterized by deep vein thrombosis on anticoagulant therapy after giving birth involves the risk of hemorrhage. Anticoagulant therapies such as heparin increase the risk of bleeding since they inhibit the blood's ability to clot effectively. This means that in the event of an injury or surgery, there is a higher likelihood of excessive bleeding. Therefore, it is crucial to monitor for signs of hemorrhage such as bruising, bleeding gums, blood in urine or stool, and low blood pressure. Intervention to manage bleeding may include reducing the dosage of the anticoagulant, administering blood products, and implementing pressure or surgical interventions as necessary.