Nokea
The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the highest priority nursing intervention?
- A. Count respirations and report a rate of less than 12 breaths/minute.
- B. Count respirations and report a rate of more than 20 breaths/minute.
- C. Check blood pressure and report a rate of less than 100/60 mm Hg.
- D. Monitor urinary output and report a rate of less than 100 mL/hr.
Correct Answer: A
Rationale: Excessive magnesium sulfate may cause respiratory depression.
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A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh antibodies from forming?
- A. Rh immune globulin during labor
- B. Intrauterine transfusions with O-negative blood
- C. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant
- D. Rh immune globulin now and again in the last trimester
Correct Answer: C
Rationale: An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after the birth of an Rh-positive infant or abortion.
The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.)
- A. Toxoplasmosis
- B. Toxemia
- C. Cytomegalovirus
- D. Rubella
- E. Herpes simplex
Correct Answer: A,C,D,E
Rationale: The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.
What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis?
- A. Frequency and urgency of urination
- B. Nausea and weight loss
- C. Burning sensation when voiding
- D. Tenderness in the flank area
Correct Answer: D
Rationale: Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills, flank pain or tenderness, nausea, and vomiting.
A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report immediately?
- A. Diarrhea
- B. Urticaria
- C. Blurred vision
- D. Backache
Correct Answer: C
Rationale: Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for effective intervention to prevent preeclampsia and convulsion.
The young prenatal patient with gestational diabetes mellitus (GDM) says, 'I am frightened that I will have to deal with insulin injections for the rest of my life.' What is the best response by the nurse?
- A. After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections.'
- B. Have you considered an insulin pump?'
- C. After a while those insulin injections won't seem so bad.'
- D. It will most likely resolve 6 weeks or so after the baby is born.'
Correct Answer: D
Rationale: GDM usually resolves by 6 weeks after delivery.