Hurst 4
A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.
1., 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. 4. Incorrect: Never place an object in a client's mouth who is experiencing a seizure. 5. Incorrect: Magnesium sulfate is administered to control BP and decrease seizures. Magnesium sulfate leads to fewer maternal deaths and fewer future seizures when given for eclamptic seizures. Diazepam is contraindicated for use in pregnancy.
In which client should the nurse question a prescription for a contraction stress test? 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa.
1., 2., & 5. Correct: 26 weeks is too early to stimulate contractions. This could lead to a preterm delivery. Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. 3. Incorrect: There is no reason to suspect complications from a contraction stress test for this client. 4. Incorrect: There is no reason to suspect complications from a contraction stress test for this client.
The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.
1., 2., 3. & 5. Correct: Consistent use of latex condoms protects against STIs. Although chlamydia may have no symptoms, burning and discharge should be reported for further evaluation. It is recommended that all sexually active young women less than 25 years of age be screened for chlamydia on an annual basis. Medication should be taken as prescribed, and rescreening should occur in 3 months to make sure that there is no more disease present.4. Incorrect: Chlamydia does not always produce visible symptoms, and, if left untreated, can lead to pelvic inflammatory disease (PID). False security may lead to unsafe sex practices.
The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.
2. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn. 1. Incorrect: This task is not emergent and can be performed later at an appropriate time. 3. Incorrect: This task is not emergent and can be performed later at anytime during the transition stage of the newborn's nursery care. 4. Incorrect: This task is not emergent and can be performed at anytime between 24 hours and 7 days old. Typically it is done before the newborn is discharged home.
A nurse is teaching a group of women about human papillomavirus (HPV). What should the nurse tell the women that human papillomavirus puts women at risk for? 1. Human immunodeficiency virus 2. Cervical cancer 3. Hepatitis B 4. Cirrhosis
2. Correct: Women who have had human papillomavirus are at increased risk for developing cervical cancer. 1. Incorrect: HPV does not increase the risk of developing HIV. HPV increases the risk for developing cervical cancer. 3. Incorrect: HPV does not contribute to Hepatitis B. HPV increases the risk for developing cervical cancer. 4. Incorrect: HPV does not contribute to Cirrhosis. HPV increases the risk for developing cervical cancer.
A nurse is helping a client to maintain normal voiding habits while recovering from a cesarean section. What methods should the nurse initiate? 1. Have the client recline slightly while using bedside commode. 2. Encourage the client to push over the pubic area with hands. 3. Suggest the client read or listen to music. 4. Pour warm water over the perineum. 5. Stay and talk with client while waiting for urge to void.
2., 3., 4. Correct: Encourage the client to push over the pubic area with the hands or lean forward to increase intraabdominal pressure and external pressure on the bladder. Reading or listening to music will help to decrease anxiety and tension. Pouring warm water over the perineum promotes muscle relaxation. 1. Incorrect: Assist the client to a normal position for voiding. For males, standing. For females, squatting or leaning slightly forward when sitting. These positions enhance movement of urine through the tract by gravity. 5. Incorrect: Provide privacy. Many people cannot void in the presence of another person.
A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What information should the nurse provide the client about spermicidal agents? 1. Effectively reduces vaginal fungal infections such as Candida albicans. 2. Eliminates bacterial and viral sexually transmitted infections. 3. Most effective when used in conjunction with barrier methods, such as a diaphragm. 4. Causes few side effects.
3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. 1. Incorrect: They do not kill fungi such as Candida albicans, even in high concentrations. 4. Incorrect: Spermicidal agents are used only when sexual intercourse is expected, but side effects include vaginal and penile irritation, lesions, and ulcerations due to the detergent effect. Disruption of normal protective vaginal flora results in an increased risk of opportunistic vaginal infections and urinary tract infections. 2. Incorrect: Spermicidal agents do not eliminate bacterial and viral STIs.
A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? 1. Lie on left side and take slow, deep breaths. 2. Call an ambulance and go to emergency room. 3. Come to the clinic for assessment and evaluation. 4. Go directly to the hospital emergency room.
3. Correct: This client is full term and the expulsion of large amounts of fluid indicates the client has experienced a rupture of membranes. The next step would be to evaluate the client for effacement and dilation as well as fetal heart tones. The best approach would be for the client come to the clinic for a quick evaluation and assessment. 1. Incorrect: This is neither safe nor appropriate. The client should be examined by the primary healthcare provider as soon as possible. Lying on the left side and taking deep breaths would be a delay of the appropriate treatment. 2. Incorrect: There is no indication the client is experiencing a situation serious enough to warrant an ambulance trip to the emergency room. The question suggests normal rupture of membranes, and while the client should be assessed, this can be accomplished without a trip to the emergency room. 4. Incorrect: It is not necessary for the client to go directly to the emergency room. Because the clinic is still open, the client could be examined by the primary healthcare provider to determine the stage of labor as well as dilation. If the client had called the clinic after hours, the nurse might have recommended a trip to the labor & delivery uni
Which client should the nurse see first? 1. Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+ 2. Multigravida on po terbutaline with a pulse rate of 110/per minute 3. Primigravida on IV oxytocin with contractions every 3-4 minutes 4. Multigravida on po methyldopa with a blood pressure of 142/90.
4. Correct: A systolic blood pressure of ≥ 140 mmHg or a diastolic BP of ≥ 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being. 1. Incorrect: + DTRs are normal. Clinical signs of safe dosage of magnesium sulfate include normal deep tendon reflexes. Adverse effects include depressed reflexes. 2. Incorrect: Maternal tachycardia (up to 120 bpm) is expected when on this medication. Terbutaline is a beta adrenergic agonist could have significant cardiovascular effects. 3. Incorrect: The desired contraction pattern with oxytocin is 3 in 10 minutes. A contraction every 3-4 minutes would equal 3 contractions in 10 minutes. The dosage of the oxytocin is individualized until the desired contraction rate is achieved.
A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 1. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."
4. Correct: This statement recognizes the mother's feelings and seeks to educate. Providing relevant information may decrease her anxiety and encourage further communication. 1. Incorrect: This statement belittles the mother's feelings and communicates that the nurse is not taking her concerns seriously. 2. Incorrect: This is nontheraputic and will discourage further expression of feelings. This response also gives false reassurance because the nurse does not know if the baby will continue to improve. 3. Incorrect: An Apgar score of 7 to 10 indicates a newborn in good condition. An Apgar score of 6 is not normal and indicates the need for interventions.
