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 caring for a patient who could be at risk for uterine
- A. What should the nurse be monitoring the fetus closely for? SATA
- B. Loss of ability to determine fetal station
- C. Bradycardia
- D. Late decelerations
Correct Answer: A
Rationale: A. What should the nurse be monitoring the fetus closely for? SATA
A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth?
- A. Pneumococcal
- B. Hepatitis
- C. Human papillomavirus
- D. Rubella
Correct Answer: D
Rationale: The CDC recommends that women who are not up-to-date with the MMR (measles, mumps, rubella) vaccine should receive it immediately postpartum. Rubella, also known as German measles, is particularly important during pregnancy because contracting rubella during pregnancy can lead to serious complications in the baby, such as birth defects and miscarriage. By ensuring the client receives the MMR vaccine postpartum, it helps protect both the mother and any future pregnancies from the risk of rubella infection.
The nurse is performing Leopold's maneuvers on a client in labor. What is the primary purpose of this assessment?
- A. Evaluate fetal heart rate.
- B. Determine fetal position and presentation.
- C. Check for uterine contractions.
- D. Assess amniotic fluid volume.
Correct Answer: B
Rationale: Leopold's maneuvers help identify fetal position, presentation, and engagement for labor management.
How should a nurse respond to a mother asking about newborn hearing screening?
- A. Explain that hearing screening is optional
- B. Reassure the mother that this is a routine test
- C. Inform the mother that hearing screening is mandatory
- D. Provide resources for further testing if needed
Correct Answer: B
Rationale: Hearing screening is a routine test to identify hearing issues early and ensure proper interventions.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.