Nokea
The nurse is caring for a patient who is receiving magnesium sulfate for pre-eclampsia. Which assessments will be of the highest priority?
- A. Assessing lung sounds
- B. Assessing blood sugar level
- C. Encouraging fluid intake
- D. Assessing for pitting edema
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate can cause respiratory depression, necessitating close monitoring of lung sounds to detect any signs of respiratory distress. Assessing lung sounds is crucial for early detection and intervention. Blood sugar level (B) monitoring is not directly related to magnesium sulfate therapy. Encouraging fluid intake (C) may be important, but not as critical as assessing lung sounds. Assessing for pitting edema (D) is important for overall assessment but not the highest priority in this scenario.
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The doctor suspects that the client is in preterm labor. Which symptom is consistent with this diagnosis?
- A. Severe pain in the lower quadrant
- B. Severe pain and hard abdomen to palpation
- C. Painless vaginal bleeding
- D. Abdominal cramping and lower back pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal cramping and lower back pain. This symptom is consistent with preterm labor as it indicates contractions and possible cervical changes. Severe pain in the lower quadrant (A) is more likely related to other conditions like ectopic pregnancy. Severe pain and hard abdomen to palpation (B) may suggest a more acute issue like placental abruption. Painless vaginal bleeding (C) is typically seen in conditions like placenta previa. Therefore, choice D is the most indicative of preterm labor based on the symptoms presented.
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
- A. Having high levels of hCG
- B. Having high blood pressure
- C. Being an adolescent
- D. Being underweight
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
- A. Prepare the woman for an abdominal ultrasound
- B. Place the patient on her left side to increase perfusion to the fetus
- C. Be prepared to discuss the action and side effects of progesterone
- D. Monitor the patient’s blood pressure closely
Correct Answer: C
Rationale: The correct answer is C because progesterone is recommended for women with a history of preterm birth due to cervical incompetency. Progesterone helps to reduce the risk of another preterm birth by supporting the cervix and preventing it from opening too early. It is important for the nurse to discuss the action and side effects of progesterone with the patient to ensure informed decision-making.
Choice A is incorrect as an abdominal ultrasound is not directly related to managing cervical incompetency. Choice B is incorrect as positioning the patient on her left side does not address the issue of cervical incompetency. Choice D is also incorrect as monitoring blood pressure is not the primary intervention for managing cervical incompetency in this case.
The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick reading of 3+ for protein indicates significant proteinuria, which can be a sign of preeclampsia in pregnancy. Preeclampsia poses serious risks to both the mother and the fetus, requiring immediate medical intervention.
Choice A: Hemoglobin and hematocrit levels within normal range for pregnancy.
Choice B: Blood pressure slightly elevated but not concerning at this gestational age.
Choice C: Slight pedal swelling is common in pregnancy and may not indicate a serious issue at this time.