min. Provider was notified of the client's status and assessment, and new orders were received.

Medical History: The client has a history of three previous pregnancies (Gravida 4 Para 3).Querry: The nurse is contacting the primary health care provider regarding the client's status.

Which of the following interventions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

Give betamethasone 12 mg IM now and repeat in 24 hr.

Begin loading dose of magnesium sulfate 9 g over 30 min.

Position the client in a lateral position.

Administer terbutaline 0.25 mg subcutaneous stat.

E. Prepare for an emergency cesarean birth

Question Solution

Correct Answer : A,B,C

Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.

Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.

Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.

Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.

Choice C: Position the client in a lateral position.

Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Weight gain B. Visual disturbances C. Blood pressure D. Respiratory rate E. Deep tendon reflexes F. Fetal heart rate

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Rapid weight gain during pregnancy, especially when accompanied by other symptoms, can be a sign of preeclampsia. This condition is characterized by high blood pressure and often occurs after 20 weeks of gestation. Reporting rapid weight gain is important for early detection and management.

Choice B rationale:

Visual disturbances, such as blurred vision, can be a warning sign of preeclampsia. It indicates potential neurological involvement and requires immediate evaluation to prevent complications for both the mother and the fetus.

Choice C rationale:

Elevated blood pressure readings are a critical sign of preeclampsia, a condition that can lead to serious health complications for both the mother and the baby if left untreated. Reporting elevated blood pressure is essential for early intervention and management.

Choice D rationale:

While the respiratory rate is slightly elevated, it is not as critical an indicator of preeclampsia as the other findings. In this case, the focus should be on more concerning symptoms, such as blood pressure and visual disturbances.

Choice E rationale:

Hyperactive deep tendon reflexes (3+) are a clinical sign of preeclampsia. The absence of clonus is a reassuring sign, but the presence of hyperactive reflexes warrants further evaluation and monitoring.

Choice F rationale:

The fetal heart rate (FHT) of 148/min is within the normal range (110-160/min) and does not indicate an immediate concern that needs to be reported. The nurse should focus on the maternal symptoms that suggest preeclampsia.

A. Client's sister had breast cancer. B. History of radiation exposure. C. Currently taking oral contraceptives. D. Age less than 25 years old.

Correct Answer is D

Explanation

Choice A rationale

A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.

Choice B rationale

Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.

Choice C rationale

Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.

Choice D rationale

Age less than 25 years is not a risk factor for breast cancer; risk increases with age.

Free Nursing Test Bank

Correct Answer is ["A","B","E"]

Explanation

Correct Answer is D

Explanation

Quick Links

Resources

Free Nursing Test Bank

Correct Answer is ["A","B","E"]

Explanation

A nurse is assessing a client's risk of breast cancer. Which of the following would not be included in the education about risks?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia. Which assessment finding would alert the nurse to suspect magnesium toxicity?

A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes. The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A nurse is caring for four newborns in a special care nursery. Which of the following newborn assessment findings requires immediate intervention?

A nurse is assessing a client who is 2 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse?

A nurse is caring for a client who is postpartum and finds the fundus boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A nurse is walking by a client's room and can hear the fetal heart rate dropping. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Quick Links

Resources