1 Focus on Maternity Exam 1. The home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. What does the nurse tell the client to do? A. Eat foods high in calories and fat B. Lie down for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and the subject , ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review: preventing nausea and vomiting Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Fluid and Electrolytes, Nutrition HESI Concepts: Fluids and Electrolytes, Nutrition Awarded 100.0 points out of 100.0 possible points. 2. The nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? A. Clonus is present. B. Magnesium level is 10 mg/dL (4.11 mmol/L). C. Deep tendon reflexes are absent. D. The client experiences diuresis within 24 to 48 hours. Correct Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 2 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent. Test-Taking Strategy: Focus on the subject , client with preeclampsia. Use the process of elimination and focus on the strategic word “effective”. This indicates that the action of the medication is appropriate. Recalling the actions of this medication and expected assessment findings after a client receives magnesium sulfate will direct you to this option. Review: magnesium sulfate infusion Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Giddens Concepts: Evidence , Perfusion HESI Concepts: Evidence -Based Practice/Evidence , Perfusion/Clotting Awarded 100.0 points out of 100.0 possible points. 3. A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: A. Vitamin K B. Protamine sulfate C. Calcium gluconate Correct D. Naloxone hydrochloride Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is admini stered to treat opioid -induced respiratory depression. Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in directing you to t he correct option. Review: common antidotes if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision -Making/Clinical Judgment, Safety Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 773). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 4. The maternity nurse is caring for a pregnant client with no history of preeclampsia who is receiving a magnesium sulfate infusion. Why is this client receiving this infusion? 3 Rationale : Magnesium sulfate is a central nervous system depressant and relaxes smooth A. To contract the uterus Correct B. To treat hypotension C. To reverse extreme muscle weakness D. To halt preterm labor contractions respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels Test-Taking Strategy: Focus on the subject , pregnant client receiving magnesium sulfate infusion. Know that magnesium sulfate is used to relax smooth muscle, not contract the muscle. Note the options that are comparable or alike in that they are related to treating hypotension and reverse extreme muscle weakness because these conditions are adverse effects of this medication. Review: Magnesium sulfate infusion Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision -Making/Clinical Judgment, Safety Awarded 100.0 points out of 100.0 possible points. 5. The nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? A. Milk B. Steak C. Chicken D. Lima beans Correct Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein. Test-Taking Strategy: Use the process of elimination and focus on the subject , source of folic acid. Note the strategic word “best”. This indicates the most appropriate source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review: foods high in folic acid Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Nutrition, Reproduction HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed muscle, including the uterus. It is used to halt preterm labor contractions and also for 4 Test-Taking Strategy: Focus on the subject, client with Spo2 of 92%. Use the process of Awarded 100.0 points out of 100.0 possible points. 6. The nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. What does the nurse tell the mother to do? A. Avoid the use of shampoo on the infant’s scalp B. Apply oil to the affected area on the infant’s scalp Correct C. Wash the infant’s scalp daily, using only tepid water D. Shampoo the infant’s scalp, avoiding the anterior fontanel area Rationale: Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation. Test-Taking Strategy: Focus on the subject , infant with seborrheic dermatitis. Use the process of elimination. Eliminate the option containing theclosed -ended word “only.” To select from the remaining options, recall that this condition is characterized by the presence of scaly lesions; this will direct you to the correct option. Review: seborrheic dermatitis (cradle cap) Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Newborn Giddens Concepts: Client Education, Tissue Integrity HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity Awarded 100.0 points out of 100.0 possible points. 7. The nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry (Spo 2) is 92%. What should the nurse do first? A. Documents the findings B. Contacts the primary health care provider C. Administers 100% oxygen by way of face mask D. Instructs the client to take several deep breaths Correct Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the Spo2 falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the primary health care provider. If the deep breaths fail to increase the oxygen saturation level, the primary health care provider is notified and may prescribe oxygen.
