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The nurse receives a phone call from a patient at 36 weeks' gestation who states they are having right upper quadrant pain that penetrates to the upper back. What priority information does the nurse need to obtain from the patient? Select 3 that apply.
- A. onset and characteristics of the pain
- B. any nausea or vomiting
- C. any vaginal discharge
- D. content of last meal
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important to determine the onset and characteristics of the pain to assess for possible causes like pre-eclampsia. B is crucial to assess for signs of liver or gallbladder issues. C is important to rule out any potential infection like chorioamnionitis. D is not relevant to the presenting symptoms and does not provide information related to the patient's condition.
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A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient's magnesium level is 7.6 mg/dL. What is the nurse's priority action?
- A. Stop the infusion of magnesium.
- B. Assess the patient's respiratory rate.
- C. Assess the patient's deep tendon reflexes.
- D. Notify the health care provider of the magnesium level.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's respiratory rate. A magnesium level of 7.6 mg/dL is above the therapeutic range (4-7 mg/dL) and can lead to magnesium toxicity. Respiratory depression is a common early sign of magnesium toxicity. Assessing the patient's respiratory rate is the priority to monitor for this potentially life-threatening complication. Stopping the infusion of magnesium (Choice A) is not the immediate priority as the patient's respiratory status needs to be assessed first. Assessing deep tendon reflexes (Choice C) is important for magnesium toxicity but not as urgent as assessing respiratory rate. Notifying the health care provider (Choice D) can be done after assessing the patient's respiratory rate.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following?
- A. Hemorrhage is the primary concern.
- B. She will be unable to conceive in the future.
- C. Bed rest and analgesics are the recommended treatment.
- D. A D&C will be performed to remove the products of conception.
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage is the primary concern. In an ectopic pregnancy, the fertilized egg implants outside the uterus, typically in the fallopian tube, which can lead to life-threatening internal bleeding. Nursing care focuses on monitoring for signs of hemorrhage, such as abdominal pain, vaginal bleeding, and signs of shock. Prompt intervention is crucial to prevent serious complications.
Explanation of why the other choices are incorrect:
B: She will be unable to conceive in the future - This statement is not true as having an ectopic pregnancy does not necessarily impact future fertility.
C: Bed rest and analgesics are the recommended treatment - Bed rest and analgesics are not the primary treatments for ectopic pregnancy, as surgical intervention is often necessary.
D: A D&C will be performed to remove the products of conception - A D&C is not typically performed for ectopic pregnancy management, as it involves the removal of tissue from inside the uterus, not the fallopian
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: The correct answer is C: Urine output >100 mL/hour. This signifies improved kidney function, a key indicator of recovery in preeclampsia. Increased urine output indicates better kidney perfusion and reduced risk of complications like renal failure. A: 1+ protein in urine suggests ongoing kidney damage. B: 2+ pitting edema in lower extremities indicates fluid retention, a common symptom of preeclampsia. D: Deep tendon reflexes +2 are not specific to preeclampsia recovery, although hyperreflexia can be seen in severe cases.
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?
- A. Saturated perineal pad in 1 hour
- B. Pain level 0 on a scale of 0 to 10
- C. Cervical dilation at 2 cm
- D. Fetal heart rate at 160 bpm
Correct Answer: B
Rationale: The correct answer is B because in placenta previa, pain is usually minimal or absent, while in abruptio placentae, there is severe abdominal pain. Saturated perineal pad (choice A) is common in both conditions. Cervical dilation (choice C) is not specific to differentiate between the two conditions. Fetal heart rate (choice D) may be normal in both conditions.
What medication is not recommended for hypertension during pregnancy due to teratogenic effects?
- A. lisinopril
- B. nifedipine
- C. labetalol
- D. hydralazine
Correct Answer: A
Rationale: The correct answer is A: lisinopril. Lisinopril is contraindicated in pregnancy due to its teratogenic effects, particularly in the first trimester. It can cause fetal harm, including renal dysfunction and skull hypoplasia. Nifedipine, labetalol, and hydralazine are considered safe options for hypertension during pregnancy with no known teratogenic effects.