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The nurse is educating a client about Braxton Hicks contractions. Which statement indicates proper understanding?
- A. They are regular and increase in intensity over time.
- B. They are irregular and usually painless.
- C. They indicate that labor is starting.
- D. They require immediate medical attention.
Correct Answer: B
Rationale: The correct answer is B because Braxton Hicks contractions are indeed irregular and typically painless contractions that occur throughout pregnancy. They are considered practice contractions and do not indicate the onset of labor. Choice A is incorrect as Braxton Hicks contractions are not regular or increasing in intensity. Choice C is incorrect because Braxton Hicks contractions do not signal the start of labor. Choice D is also incorrect as Braxton Hicks contractions are a normal part of pregnancy and do not require immediate medical attention.
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The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.
In addition to the bolus of fluid which medication should she be given to increase blood pressure?
- A. Ephedrine
- B. Terbutaline
- C. Epinephrine
- D. Epifoam
Correct Answer: A
Rationale: The correct answer is A: Ephedrine. Ephedrine is a sympathomimetic amine that acts on alpha and beta adrenergic receptors to increase blood pressure. It is commonly used to treat hypotension. Terbutaline (B) and Epinephrine (C) are bronchodilators that can lower blood pressure. Epifoam (D) is a topical medication for skin conditions and does not affect blood pressure. Therefore, Ephedrine is the most appropriate choice to increase blood pressure in this scenario.
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
- A. Respiratory depression
- B. Facial flushing
- C. Nausea
- D. Drowsiness
Correct Answer: A
Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.
The nurse is teaching a client about preterm labor prevention. What instruction is most appropriate?
- A. Drink at least 8–10 glasses of water daily.
- B. Avoid lying down during the day.
- C. Increase physical activity levels.
- D. Reduce protein intake.
Correct Answer: A
Rationale: The correct answer is A because adequate hydration helps prevent preterm labor by maintaining amniotic fluid levels and preventing dehydration-induced contractions. Drinking 8-10 glasses of water daily ensures proper hydration.
B is incorrect because lying down during the day does not have a direct impact on preterm labor prevention.
C is incorrect as excessive physical activity can sometimes trigger preterm labor instead of preventing it.
D is incorrect as protein intake is important for fetal development and reducing it can lead to nutritional deficiencies, but it is not a direct factor in preventing preterm labor.
A client in her third trimester complains of Braxton
- A. Report any stools that appear to have milk Hicks contractions. Which of the following interven- curds immediately to the infant's health care tions would help with this type of pain? Select all that provider. apply.
- B. Stools will change from green to yellowish brown
- C. Drink four to six glasses of water per day. to golden yellow over the next several days.
- D. Rest until the contractions subside.
Correct Answer: D
Rationale: The correct answer is D: Rest until the contractions subside. During Braxton Hicks contractions, rest can help alleviate the discomfort. It allows the body to relax and reduces the intensity of the contractions. Other options are incorrect because:
A: Reporting stools with milk curds to the infant's healthcare provider is unrelated to Braxton Hicks contractions.
B: Stool color changes are irrelevant to managing Braxton Hicks contractions.
C: Drinking water is important for overall health during pregnancy but does not directly address Braxton Hicks contractions.