Nokea
The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. Which of the following would the nurse expect the physician to order?
- A. Frequent assessments of cervical dilation.
- B. Intravenous oxytocin administration.
- C. Vaginal culture for Neisseria gonorrhoeae.
- D. Sonogram for amniotic fluid volume index.
Correct Answer: C
Rationale: Vaginal cultures help identify infections after membrane rupture.
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Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the physician orders a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/minute.
- B. Patellar reflex of +2.
- C. Blood pressure of 160/88 mm Hg.
- D. Urinary output exceeding intake.
Correct Answer: A
Rationale: A respiratory rate of 12 breaths/minute indicates potential magnesium sulfate toxicity.
A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a midline episiotomy and a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important?
- A. Constipation.
- B. Diarrhea.
- C. Excessive bleeding.
- D. Rectal fistulas.
Correct Answer: C
Rationale: Excessive bleeding is critical to assess due to the risk of hemorrhage with a third-degree laceration.
A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. The nurse should tell the client that the test results indicate which of the following?
- A. A contraction stress test is necessary.
- B. The nonstress test should be repeated.
- C. Chorionic villus sampling is necessary.
- D. There is evidence of fetal well-being.
Correct Answer: D
Rationale: Reactive nonstress test indicates fetal well-being.
The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results?
- A. Platelets 200,000 mm3.
- B. Lactate dehydrogenase(LDH)> 200 units/L.
- C. Uric acid 3 mg/dL.
- D. Aspartate aminotransferase(AST) 15 units/L.
Correct Answer: B
Rationale: Elevated LDH indicates possible hemolysis in HELLP syndrome.
When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently?
- A. 5 to 7 months.
- B. 8 to 10 months.
- C. 12 to 14 months.
- D. 15 to 16 months.
Correct Answer: C
Rationale: Most babies can drink from a cup independently by 12-14 months as motor skills develop.