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The nurse is caring for a client with severe preeclampsia. What is the priority nursing action?
- A. Administer antihypertensive medication.
- B. Assess for signs of impending eclampsia.
- C. Monitor urine protein levels.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Assessing for signs of impending eclampsia, such as severe headache or visual changes, is critical to prevent seizures.
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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 teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: C
Rationale: Neonatal weight loss in the first 3 days of life is most often the result of inadequate breast or formula feeding. During the initial days of life, it is normal for newborn babies to experience some weight loss. This weight loss is generally due to factors such as insufficient intake of breast milk or formula. It takes a few days for a mother's mature breast milk to come in, and during this time, a newborn may not receive enough colostrum, which can lead to initial weight loss. Similarly, if a baby is not getting enough formula or is having feeding difficulties, this can also result in weight loss. Allergy to formula, a hypoglycemic response, or excretion of fluid via lungs, urinary bladder, and bowels are less likely explanations for neonatal weight loss in the first 3 days of life compared to inadequate feeding.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
- A. Discontinue the medication infusion.
- B. Prepare for an emergency cesarean birth.
- C. Assess maternal blood glucose.
- D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: The most appropriate action for the nurse to take in this situation is to discontinue the medication infusion. The client is showing signs of magnesium sulfate toxicity, which can include respiratory depression (low respiratory rate) and absent deep-tendon reflexes. These are early signs of magnesium toxicity, and prompt action is needed to prevent further complications. Discontinuing the medication infusion will help reduce the risk of magnesium toxicity worsening. The other options are not appropriate in this situation as they do not address the immediate concern of magnesium toxicity.
What does the nursing process describe?
- A. what nurses do
- B. how nurses think
- C. where nurses provide care
- D. who nurses care for
Correct Answer: B
Rationale: The nursing process describes how nurses think and approach patient care. It is a systematic problem-solving approach that nurses use to provide individualized patient care. The nursing process consists of five main steps: assessment, diagnosis, planning, implementation, and evaluation. Through this process, nurses gather information, identify patient problems, set goals, implement interventions, and evaluate outcomes. By following the nursing process, nurses can deliver holistic and effective care to their patients.
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.