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Focus on Maternity Exam.
Focus on Maternity Exam.
[Meer zien]Voorbeeld 4 van de 65 pagina's
Voorbeeld 4 van de 65 pagina's
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Voorbeeld van de inhoud
Focus on Maternity Exam1.
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
, 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 administered 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 the 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?
, A. To contract the uterus Correct
B. To treat hypotension
C. To reverse extreme muscle weakness
D. To halt preterm labor contractions
Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth
muscle, including the uterus. It is used to halt preterm labor contractions and also for
preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed
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
, 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 (Spo2) 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.
Test-Taking Strategy: Focus on the subject, client with Spo2 of 92%. Use the process of
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