Nokea
The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
- A. Insert a Foley catheter with a urimeter to monitor hourly output
- B. Have calcium gluconate immediately available
- C. Provide a quiet environment with subdued lighting.
- D. Assess deep tendon reflexes (DTRS) every 4 hours.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause neuromuscular blockade, making calcium gluconate, the antidote, critical to have immediately available in case of toxicity signs like loss of deep tendon reflexes.
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A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema
- B. Ascertain the frequency of headaches
- C. Evaluate for history of cluster headaches
- D. Observe and time client's contractions
Correct Answer: A
Rationale: Elevated blood pressure at 32 weeks may suggest preeclampsia. Inspecting for facial edema is a priority to assess for fluid retention, a key sign of this condition.
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?
- A. Assign a practical nurse (PN) to reassess the client's vital signs.
- B. Obtain a STAT hemoglobin and hematocrit
- C. Notify the healthcare provider of the assessment findings
- D. Determine if the client received anesthesia during delivery
Correct Answer: C
Rationale: A severe headache post-delivery may indicate a post-dural puncture headache, especially if anesthesia was used, requiring immediate notification of the healthcare provider.
A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?
- A. Chromosomal abnormalities
- B. Sex and size of the infant
- C. Lecithin-sphingomyelin ratio
- D. Fetal growth and gestational age.
Correct Answer: D
Rationale: A routine ultrasound at 20 weeks primarily assesses fetal growth and gestational age to ensure proper development.
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Flaring of the nares
- B. Shallow and irregular respirations
- C. Respiratory rate of 50 breaths per minute
- D. Abdominal breathing with synchronous chest movement
Correct Answer: A
Rationale: Flaring of the nares is a specific sign of respiratory distress in newborns, indicating increased effort to breathe. It is more immediate and specific than other options.
The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Cries vigorously when stimulated
- B. A positive Babinski reflex
- C. Heart rate of 220 beats/minute
- D. Flexion of all four extremities
Correct Answer: A
Rationale: Vigorous crying indicates effective breathing and responsiveness, key signs of successful transition to extrauterine life.