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Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
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A nurse is reinforcing teaching with a client about various contraceptive methods.
Which of the following statements should the nurse include in the teaching?
- A. Combined estrogen-progestin contraceptive pills cause longer periods.
- B. You will need to have your diaphragm replaced every 4 years.
- C. Oral contraceptives decrease the risk for endometrial cancer.
- D. You will need to receive a medroxyprogesterone acetate injection once per month.
Correct Answer: C
Rationale: Combined oral contraceptives reduce the risk of endometrial cancer by suppressing ovulation and stabilizing hormone levels, preventing endometrial proliferation.
A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup sweet white corn
- B. 1 cup kale
- C. 1 baked potato
- D. 1 large banana
Correct Answer: B
Rationale: Kale is a rich plant-based source of calcium, providing approximately 90 mg per cup, ideal for those avoiding dairy.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Administer NSAIDs every 4 to 6 hr.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Have the client ambulate as often as possible.
Correct Answer: D
Rationale: Early and frequent ambulation promotes circulation, reducing venous stasis and the risk of thrombophlebitis.
Nurses' Notes: Newborn lightly swaddled, jittery, weak cry, mottled extremities, acrocyanosis, rapid respirations. History: Gravida 2 Para 2, vaginal birth at 41 weeks, maternal syphilis treated, intermittent cannabis use. Vital Signs: Temp 36°C, HR 132/min, RR 72/min, Weight 4,366 g. Diagnostic Results: Maternal blood type A+, RPR/VDRL negative, urine drug screen positive for marijuana.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
- A. Collect a urine specimen, Monitor the new born after receiving penicillin IM, Reinforce with the parent to feed the newborn, Anticipate a prescription to obtain a capillary blood, Monitor the new born while receiving phototherapy
- B. Hypoglycaemia, Kernicterus, Congenital Syphilis, Neonatal abstinence syndrome
- C. Skin integrity, Bilirubin levels, Respiratory Status, Environmental stimuli, Temperature
Correct Answer: A
Rationale: Jitteriness, weak cry, and large birth weight suggest hypoglycemia. Feeding stabilizes glucose, and capillary blood confirms diagnosis. Monitoring respiratory status and temperature assesses progress.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever
- B. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.