Nokea
The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. Deep tendon reflexes +4.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.
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During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices:
A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue.
B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern.
C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.
The nurse is educating a pregnant client about foods high in iron. Which food should be recommended?
- A. Milk.
- B. Chicken.
- C. Spinach.
- D. Bananas.
Correct Answer: C
Rationale: The correct answer is C: Spinach.
1. Spinach is high in iron, which is important for pregnant women to prevent anemia.
2. Milk (A) does not contain a significant amount of iron.
3. Chicken (B) is a good source of protein but not as high in iron as spinach.
4. Bananas (D) are rich in potassium but not iron, making them a less suitable choice for iron supplementation during pregnancy.
A nurse is checking postpartum orders, the doctor prescribed bed rest for 6-12 h. The nurse knows this is an appropriate order if the patient had which type of anesthesia?
- A. Spinal
- B. Pudendal
- C. Epidural
- D. General
Correct Answer: C
Rationale: The correct answer is C: Epidural. The rationale for this is that epidural anesthesia is a regional anesthesia that numbs the lower half of the body while allowing the patient to remain conscious. Therefore, prescribing bed rest for 6-12 hours after receiving an epidural is appropriate to ensure the anesthesia wears off gradually and the patient does not experience any complications while regaining sensation and mobility.
Summary of Incorrect Choices:
A: Spinal anesthesia also numbs the lower half of the body, but it typically wears off faster than an epidural, so bed rest may not be necessary for as long.
B: Pudendal anesthesia is specific to numbing the perineum area and does not affect mobility in the same way as epidural anesthesia.
D: General anesthesia does not target a specific area of the body and does not require bed rest for 6-12 hours postpartum.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.
The nurse is assessing a client with suspected chorioamnionitis. What is the priority nursing assessment?
- A. Assess for foul-smelling vaginal discharge.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check maternal glucose levels.
Correct Answer: C
Rationale: The correct answer is C: Evaluate fetal heart rate. In chorioamnionitis, fetal distress can occur due to infection and inflammation of the fetal membranes. Monitoring fetal heart rate is crucial to assess the well-being of the baby. Assessing for foul-smelling discharge (A) is important but not the priority. Monitoring maternal blood pressure (B) and checking glucose levels (D) are relevant assessments but do not address the immediate risk of fetal distress in chorioamnionitis.