A patient, 32 weeks pregnant with severe headache, is admitted to… A

A patient, 32 weeks pregnant with severe headache, is admitted to… A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first?a)    Assess deep tendon reflexes.b) Obtain complete blood count.c) Assess baseline weight.d) Obtain routine urinalysis. 2. A 24-week-gravid client is being seen in the prenatal clinic. She states, “I have had a terrible headache for the past twodays.”  Which of the following is the most appropriate action for the nurse to perform next?a) Inquire whether or not the client has allergies.b) Take the woman’s blood pressure.c) Assess the woman’s fundal height.d) Ask the woman about stressors at work. 3. A nurse remarks to a 38-week-gravid client, “It looks like your face and hands are swollen.”  The client responds, “Yes, you’re right. Why do you ask?”  The nurse’s response is based on the fact that the changes may be caused by which of the following?a) Altered glomerular filtration.b) Cardiac failure.c) Hepatic insufficiency.d) Altered splenic circulation. 4. The primary expected outcome for care associated with the administration of magnesium sulfate would be met if the womana) Exhibits a decrease in both systolic and diastolic BP.b) States she feels more relaxed and calm.c) Experiences no seizures.d) Urinates more frequently, resulting in a decrease in pathologic edema.  5. The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section:  Risk for ineffective individual coping related to emergency procedure. Which of the following nursing interventions would be appropriate in relation to this diagnosis?a) Apply anti-embolic boots bilaterally.b) Explain all procedures slowly and carefully.c) Administer an antacid per MD orders.d) Monitor the fetal heart and maternal vital signs. 6. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what other interventions should be performed?e) Slow the intravenous flow rate.f) Place the client in a high Fowler’s position.g) Continue the oxytocin (Pitocin) drip if infusing.h) Administer oxygen, 8 to 10 L/min, via face mask. 7. A nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is an initial nursing action?e) Gently push the cord into the vagina.f) Place the client in Trendelenburg’s position.g) Find the closest telephone and call the physician.h) Call the OR to notify the staff that the client will be transported immediately. 8. A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochia flow as:e)    Scant.f)    Light.g) Heavy.h) Excessive. 9. When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes they are larger than 1 cm. Which nursing action is appropriate?a) Weigh the clots.b) Document the findings.c) Reassess the client in 2 hours.d) Encourage increased oral intake of fluids.  10. A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following signs, if noted, would be an early sign of excessive blood loss?i) A temperature of 100.4 F.j) A blood pressure changes from 130/88 to 124/80 mm Hg.k) An increase in the pulse rate from 88 to 102 beats/min.l) An increase in the respiratory rate from 18 to 22 breaths/min. 11. A nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?a) A primiparous client who delivered 4 hours ago and delivered a 7 lb. 2 oz infant.b) A primiparous client who delivered 2 hours ago and had her placenta manually removed.c) A multiparous client who delivered 6 hours ago and had a labor epidural.d) A multiparous client who delivered 2 hours ago and had a labor induction. 12. A mother, G4P4004, is 15 minutes postpartum. Her baby weighed 4595 grams at birth. For which of the following complications should the nurse monitor this client?a) Seizures.b) Hemorrhage.c) Infection.d) Thrombosis.                                                              Health Science Science Nursing NURS 112 Share EmailCopy link Comments (0)

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