Question 6021)
A client is receiving magnesium sulfate therapy for severe pre-eclampsia. What initial sign of toxicity should alert the nurse to intervene?
A. Hyperactive sensorium
B. Increase in respiratory rate
C. Lack of the knee-jerk reflex
D. Development of a cardiac dysrhythmia
Answer: C
Explanation: Magnesium sulfate has a CNS depressant effect,toxic levels will be reflected by the loss of the kneejerk reflex.
Question 6022)
A client is admitted to the high-risk unit in preterm labor. A loading dose of 6 g of magnesium sulfate over 20 minutes is prescribed to be followed by 2 g/hr. Premixed stock is available with 40 grams of magnesium sulfate in 100 mL of D5W. At how many milliliters should a nurse set the infusion pump to complete the loading dose?
A. 150
B. 200
C. 450
D. 350
Answer: C
Explanation: 450 ml. Use the "Desire over Have" formula to solve the problem by using ratio and proportion. Desire / have = 6g/40g = xml/100ml -> 40x = 6000, X = 6000/40, X = 150. An infusion pump is set at milliliters per hour. 150 mL is needed in 20 minutes. There are 60 minutes in an hour, therefore , 3 x 150 = 450 mL/hr. Question
6023)
A nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate?
A. Hypotension
B. Decreased fetal heart rate
C. Unusual uterine enlargement
D. Painless, heavy vaginal bleeding
Answer: C
Explanation: The proliferation of trophoblastic tissue filled with fluid causes the uterus to enlarge more quickly than if a fetus were in the uterus.
Question 6024)
An expectant couple ask the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the position of the fetus is:
A. Breech
B. Transverse
C. Occiput anterior.
D. Occiput posterior
Answer: D
Explanation: A persistent occiput posterior position causes intense back pain because of fetal compression of the maternal sacral nerves.
Question 6025)
itz baths are ordered for a client with an episiotomy during the postpartum period. A nurse encourages her to take the sitz baths because they aid the the healing process by:
A. promoting vasodilation
B. cleansing perineal tissue
C. softening the incision site.
D. tightening the rectal sphincter
Answer: A Explanation: Heat causes vasodilation and an increased blood supply to the area.
Question 6026)
An infant is born precipitously in the emergency department. What should the nurse do first?
A. Tie and cut the umbilical cord.
B. Establish an airway for the newborn.
C. Ascertain the condition of the uterine fundus.
D. Arrange transport for mother and infant to the birthing unit.
Answer: B
Explanation: The nurse should position the newborn with head slightly lower than the chest to allow mucus to flow by gravity and then rub the back to stimulate crying, which promotes oxygenation.
Question 6027)
Why does a nurse encourage continued health care supervision for a pregnant woman with pyelonephritis?
A. Preeclampsia frequently occurs after pyelonephritis.
B. Antibiotic therapy should be administered until the urine is sterile.
C. Pelvic inflammatory disease can occur with untreated pyelonephritis.
D. Nutritional needs change to accommodate the prescribed low-protein diet.
Answer: B
Explanation: Healthcare supervision requires treatment with an appropriate antibiotic until two cultures of urine are negative, recurring pyelonephritis often leads to preterm birth.
Question 6028)
A client arrives at the hospital at 38 weeks gestation with profuse vaginal bleeding. She states that it occurred suddenly without any contractions. Which condition may the client be experiencing that requires immediate notification of the health care provider?
A. Placenta previa
B. Placenta accreta
C. Ruptured uterus
D. Concealed abruptio
Answer: A
Explanation: Placenta previa is classically painless bleeding, the placenta partially or completely covers the cervical os, and the cervix dilates, the placenta separates and bleeds.
Question 6029)
A client in the prenatal clinic is diagnosed with pre-eclampsia. What clinical findings support this diagnosis?
A. Elevated blood pressure of 150/100 mm Hg
B. Elevated blood pressure that is accompanied by a headache
C. Blood pressure above the baseline while fluctuating at each reading
D. Blood pressure more than 140 mm Hg systolic accompanied by proteinuria
Answer: D
Explanation: A blood pressure more than 140 mm Hg systolic and 90 mm Hg diastolic along with proteinuria is diagnostic of preeclampsia, assessments should be done twice 4 to 6 hours apart.
Question 6030)
When does a nurse caring for a client with eclampsia determine that the risk for another seizure has subsided?
A. After birth occurs
B. After labor begins
C. 48 hours postpartum
D. 24 hours postpartum
Answer: C
Explanation: The danger of a seizure in a woman with eclampsia subsides when postpartum diuresis has occurred, usually 48 hours after birth, however, the risk for seizures may remain for up to 2 weeks postpartum.
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