Nokea
Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
- A. Decreased generalized edema within 8 hours.
- B. Decreased urinary output during the first 24 hours.
- C. Sedation and decreased reflex excitability within 48 hours.
- D. Absence of any seizure activity during the first 48 hours.
Correct Answer: D
Rationale: Preventing seizures is the priority in managing severe preeclampsia.
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At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?
- A. Total weight gain.
- B. Short stature.
- C. Adolescent age group.
- D. Proteinuria.
Correct Answer: C
Rationale: Adolescents are at higher risk for preeclampsia due to incomplete physical maturity.
The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine discharge plans. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?
- A. Ask the nurses in SCN if they can take the newborn with possible sepsis now.
- B. Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms.
- C. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave.
- D. Ask the nurse with the infant who is breathing at 80 bpm to wait ½ hour.
Correct Answer: C
Rationale: Calling social services to expedite discharge of one of the waiting infants allows space for the new admission with a high respiratory rate, which requires urgent assessment.
A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should:
- A. Offer the client a carbonated beverage twice daily.
- B. Tell the client to use a straw when drinking fluids.
- C. Limit the client to a soft diet until more bowel sounds exist.
- D. Encourage ambulation in the hallway.
Correct Answer: D
Rationale: Ambulation promotes bowel motility, relieving abdominal distention.
A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, 'The baby's coming!' To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate?
- A. You're right, the baby is coming, so just relax.'
- B. Please don't push because you'll tear your cervix.'
- C. Your doctor will be here as soon as possible.'
- D. I'll explain what's happening to guide you as we go along.'
Correct Answer: D
Rationale: Explaining the process and guiding the client during a precipitous delivery promotes cooperation and reduces anxiety. Telling her to relax is unhelpful, warning against pushing is inaccurate (cervix is fully dilated), and focusing on the doctor's arrival is irrelevant.
After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.