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The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
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The nurse suspects that a client has an early sign of ectopic
- B. Abdominal pain
- C. Vaginal spotting or light bleeding
- D. Pelvic pain
Correct Answer: C
Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension as a common complication. This occurs because the local anesthetic affects the sympathetic nerves, leading to vasodilation and subsequent lowering of blood pressure. It is crucial for nurses to monitor the client's blood pressure closely and be prepared to administer IV fluids or medications to address the hypotension promptly. Vomiting, tachycardia, and respiratory depression are not typically associated with epidural anesthesia; therefore, hypotension is the most likely complication to be identified in this scenario.
When the nurse is assisting a person desiring contraception, a history and physical is done. What is an important question the nurse should ask?
- A. What is your education level?
- B. Have you ever been pregnant?
- C. Are you married?
- D. What is your exercise routine?
Correct Answer: B
Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.