Nokea
When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?
- A. Oxytocin infusion solution.
- B. Disposable tongue blades.
- C. Portable ultrasound machine.
- D. Padding for the side rails.
Correct Answer: D
Rationale: Padding for the side rails is necessary to prevent injury during potential seizures.
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The client is breast-feeding and asks the nurse about nutrition and diet. Which of the following statements by the client indicate understanding of dietary needs to promote successful breastfeeding? Select all that apply.
- A. I need to increase the number of meals I eat from three to five each day.
- B. I have to add about 500 more calories to my diet while I breast-feed.
- C. I need at least two servings of protein, like meat or eggs, with each meal.
- D. I need to double my fluids from my normal three to six glasses each day.
- E. I can eat more cheese and drink orange juice with calcium to increase my calcium intake.
Correct Answer: B,E
Rationale: An additional 500 calories and increased calcium intake are correct for breastfeeding; the other statements are inaccurate or excessive.
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do first?
- A. Insert an airway to improve oxygenation.
- B. Note the time when the seizure begins and ends.
- C. Call for immediate assistance.
- D. Turn the client to her left side.
Correct Answer: D
Rationale: Turning the client to her left side helps maintain airway patency and prevents aspiration.
The nurse is assessing a multigravida client at 12 weeks' gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which of the following should the nurse obtain about the client's history? Select all that apply.
- A. History of sexually transmitted infections.
- B. Number of sexual partners.
- C. Last menstrual period.
- D. Cesarean section.
- E. IUD use.
- F. Contraceptive use.
Correct Answer: A,B,C,E,F
Rationale: These factors increase the risk of ectopic pregnancy.
The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
- A. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
- B. A primipara who is 100% effaced, 8 cm dilated, and ready to push.
- C. A multipara who thinks her water broke 2 hours ago.
- D. A multipara with contractions every 5 minutes who is 3 cm dilated.
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa(Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?
- A. "I need to reduce my caloric intake to 1,200 calories a day."
- B. "A regular diet is recommended during pregnancy."
- C. "I should eat more frequent meals if I get heartburn."
- D. "I need to consume more fluids and fiber each day."
Correct Answer: A
Rationale: Reducing caloric intake too much can be harmful during pregnancy.