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The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?
- A. Improving kidney function.
- B. Supporting liver health.
- C. Preventing arrhythmias.
- D. Lowering cholesterol levels.
Correct Answer: A
Rationale: Hydralazine's vasodilation lowers blood pressure, improving renal perfusion and kidney function, critical in preeclampsia management.
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A new parent asks the nurse about an area of swelling on the baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?
- A. “That is called caput succedaneum. It will have to be drained.â€.
- B. “That is called a cephalhematoma. It can cause jaundice as it is absorbed.â€.
- C. “That is called a cephalhematoma. It will cause no problems.â€.
- D. “That is called caput succedaneum. It will absorb and cause no problems.â€.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: D
Rationale: Caput succedaneum is swelling across suture lines that resolves spontaneously, unlike cephalhematoma, which is confined and may cause jaundice.
A client who delivered vaginally 18 hours ago develops a slight fever. The client's delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?
- A. SROM for 36 hours.
- B. Labor lasting for 24 hours.
- C. Third-degree perineal laceration.
- D. Epidural anesthesia.
Correct Answer: A
Rationale: Prolonged SROM significantly increases the risk of postpartum endometritis due to extended exposure to pathogens.
A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
- A. Start oxytocin infusion immediately.
- B. Begin oxytocin 4 hours after misoprostol is given.
- C. Ambulate the client after administration of misoprostol.
- D. Administer misoprostol every 2 hours.
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?
- A. Variable decelerations.
- B. Late decelerations.
- C. No decelerations.
- D. Early decelerations.
Correct Answer: B
Rationale: The described pattern matches late decelerations, indicating potential utero-placental insufficiency, as the fetal heart rate decreases after the contraction starts and recovers post-contraction.