Question

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

Answer 1

Correct Answers:

Report of headache.

Rationale :

🟪 A persistent headache is a common symptom of severe preeclampsia due to cerebral vasospasm or hypertension.

🟪 Other expected findings may include visual disturbances, epigastric pain, and proteinuria.

🟪 The headache is often described as frontal or throbbing and is unrelieved by usual measures.

🟪 It indicates neurological involvement, which increases the risk for seizures (eclampsia).

🟪 This symptom requires prompt monitoring and magnesium sulfate therapy.

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Answer 2

Correct Answers:

"We can time your pain medication so that you have an hour or two before the next feeding."

Rationale :

🔷 Timing pain medication allows peak drug levels to decrease before the next breastfeeding session.

🔷 This strategy minimizes infant exposure to the drug through breast milk.

🔷 Pain control enhances maternal comfort, improves let-down reflex, and supports effective breastfeeding.

🔷 Most analgesics compatible with breastfeeding are safe when appropriately timed.

🔷 The nurse must balance pain relief with maternal preferences and newborn safety.

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Answer 3

Correct Answers:

Postpartum hemorrhage.

Rationale :

🟨 Methylergonovine is an ergot alkaloid that causes sustained uterine contractions to prevent or treat postpartum hemorrhage (PPH).

🟨 It is indicated when the uterus is not contracting effectively after delivery.

🟨 The medication increases uterine tone, reducing uterine atony, a leading cause of PPH.

🟨 It is contraindicated in hypertension due to its vasoconstrictive effect.

🟨 The nurse must monitor blood pressure and bleeding status after administration.

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Answer 4

Correct Answers:

Hypotension.

Rationale :

🟥 A common and potentially serious complication of epidural anesthesia is maternal hypotension.

🟥 It results from vasodilation and decreased venous return due to sympathetic blockade.

🟥 Hypotension can lead to fetal hypoxia, evidenced by non-reassuring fetal heart patterns.

🟥 The nurse must monitor maternal blood pressure frequently and intervene promptly.

🟥 Fluids, positioning, and possibly vasopressors are used to correct the drop.

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Answer 5

Correct Answers:

"It assists in identifying the location of the placenta and fetus."

Rationale :

🟩 Ultrasound guidance is essential before amniocentesis to locate the fetus and placenta.

🟩 This helps prevent accidental injury during needle insertion into the amniotic sac.

🟩 It also verifies amniotic fluid volume and fetal viability.

🟩 The use of ultrasound makes the procedure safer and more accurate.

🟩 It is a standard pre-amniocentesis precaution.

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Answer 6

Correct Answers:

Suction the nose with a bulb syringe.

Rationale :

🟧 Immediate suctioning of the mouth first, then nose, is the correct priority for clearing a newborn’s airway.

🟧 Secretions can obstruct breathing and lead to aspiration or respiratory distress.

🟧 Mouth suctioning prevents aspiration of secretions during crying or gasping.

🟧 A bulb syringe is safe, effective, and preferred for initial airway management.

🟧 This is consistent with neonatal resuscitation protocols.

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Answer 7

Correct Answers:

Place the client in a lateral position.

Rationale :

🟦 Lateral positioning improves venous return, increases cardiac output, and enhances uteroplacental perfusion.

🟦 This is the first-line intervention for maternal hypotension, especially following epidural anesthesia.

🟦 It relieves pressure on the inferior vena cava, a key contributor to post-epidural hypotension.

🟦 Fetal heart rate of 140/min is reassuring, so the priority is correcting maternal hypotension.

🟦 Once repositioned, other measures like IV fluids or vasopressors may follow.

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Answer 8

Correct Answers:

Cervical dilation.

Rationale :

🟪 Cervical change, particularly dilation and effacement, is the most definitive sign that a client is in true labor.

🟪 Pain or fluid leakage alone is not sufficient without cervical progression.

🟪 In labor, the cervix undergoes measurable softening, thinning, and opening.

🟪 Monitoring dilation confirms whether contractions are producing effective labor.

🟪 The presence of cervical change guides admission and labor management decisions.

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Answer 9

Correct Answers:

Administer magnesium sulfate IV.
Provide a dark, quiet environment.
Ensure that calcium gluconate is readily available.

Rationale :

Administer magnesium sulfate IV

🟫 Magnesium sulfate is the drug of choice for seizure prophylaxis in severe gestational hypertension.

🟫 It stabilizes neuronal membranes and prevents eclampsia.

🟫 Close monitoring of deep tendon reflexes and respiratory status is required.

Provide a dark, quiet environment

🟫 Reduces sensory stimulation, which can trigger seizures in clients with preeclampsia.

🟫 Supports neurological stability and comfort.

🟫 A calm environment helps minimize stress and blood pressure elevation.

Ensure that calcium gluconate is readily available

🟫 It serves as the antidote to magnesium toxicity.

🟫 Should be kept at bedside when magnesium sulfate is administered.

🟫 Readiness to respond prevents complications like respiratory depression.

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Answer 10

Correct Answers:

Place the client in the lateral position.

Rationale :

🟥 Late decelerations are caused by uteroplacental insufficiency and require immediate action to improve oxygenation.

🟥 Lateral positioning increases blood flow to the uterus and placenta, improving fetal oxygenation.

🟥 It is the first priority before fluid bolus or oxygen to reduce fetal distress.

🟥 This maneuver reduces vena cava compression, which can worsen fetal hypoxia.

🟥 Prompt intervention can restore normal fetal heart patterns and prevent complications.

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Custom: NUR 2463 FINAL EXAM 2024

No.

1 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

2 :
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "l don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

3 :
A nurse is preparing to administer methylergonovine 1M to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

4 :
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as complication from the epidural block?

5 :
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client as why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

6 :
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

7 :
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

8 :
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

9 :
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

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Custom: NUR 2463 FINAL EXAM 2024

No.

1 : A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

2 : A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "l don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

3 : A nurse is preparing to administer methylergonovine 1M to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

4 : A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as complication from the epidural block?

5 : A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client as why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

6 : A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

7 : A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

8 : A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

9 : A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

1 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

2 :
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "l don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

3 :
A nurse is preparing to administer methylergonovine 1M to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

4 :
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as complication from the epidural block?

5 :
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client as why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

6 :
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

7 :
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

8 :
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

9 :
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)