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The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration?
- A. Pulmonary edema
- B. Hyperglycemia
- C. Hyporeflexia
- D. Increased fetal movement
Correct Answer: C
Rationale: Hyporeflexia is a sign of magnesium toxicity, a critical complication to monitor during administration.
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The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?
- A. Stop! You will kill your baby.
- B. That is a nice, tight swaddle. It will help soothe your new baby.
- C. May I help you? We must be careful with the baby's intestines since we do not want the swaddle to push them back inside.
- D. Swaddling is not allowed for these babies; please stop.
Correct Answer: C
Rationale: This statement educates the parent gently, explaining the risk to the omphalocele without alarming them.
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
- A. Major Depressive Disorder
- B. Attention Deficit Hyperactivity Disorder
- C. Obsessive-Compulsive Disorder
- D. Generalized Anxiety Disorder
- E. Bipolar Disorder
Correct Answer: A, C, D
Rationale: Sertraline, an SSRI, is indicated for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety Disorder, but not for ADHD or Bipolar Disorder.
The nurse is providing dietary education to a client with renal failure who is receiving hemodialysis. The nurse determines that the teaching has been effective when the client selects which items from the menu?
- A. Blueberries, cream of wheat, coffee
- B. Bacon, banana, orange juice
- C. Sausage, eggs, tomato juice
- D. Cured pork, grits, kiwi
Correct Answer: A
Rationale: Blueberries and cream of wheat are low in potassium and phosphorus, suitable for renal failure. The other options contain high-potassium or high-phosphorus foods (e.g., banana, orange juice, tomato juice).
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
The following scenario applies to the next 1 items
The nurse cares for a primigravida in labor.
Item 1 of 1
Nurses’ Note
1940: The client is alert and fully oriented. The client is talkative and has an anxious affect. Cervical dilation of 6 cm with 100% effacement. No vaginal discharge was noted. Contractions are noted every 2-3 minutes, lasting 40-60 seconds with moderate intensity.
Fetal Heart Rate
Continuous fetal heart monitoring (FHR): 130-145/minute with normal variability.
Vital Signs
• Oral Temperature 98o F (37o C)
• Heart rate 84/minute
• Respirations 20/minute
• Blood pressure 131/72 mm Hg
• Oxygen saturation 95% on room air
The nurse reviews the client's clinical data.
Drag a word from the choices below to complete the sentence.
Based on the clinical data, the client is in the ___ stage of labor. Specifically, the ___ phase.
- A. first
- B. second
- C. third
- D. fourth
- E. latent
- F. active
- G. transition
Correct Answer: A, F
Rationale: Cervical dilation of 6 cm with 100% effacement and frequent contractions indicate the first stage of labor, active phase.