Author: Anonymous

A client at 34 weeks gestation with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse’s most recent assessment reveals: respiratory rate 10/min, patellar deep tendon reflexes absent, urine output 20 mL over the past hour, and the client reports feeling drowsy. Which action should the nurse take first?

A nurse assesses a newborn and observes the following reflexes: Babinski, Moro, Rooting and Palmar Grasp.The nursing student asks when these reflexes normally disappear. Which answer is correct?

A client at 14 weeks gestation who works as a school nurse asks whether she can receive the influenza vaccine, Tdap vaccine, varicella vaccine, and MMR vaccine during pregnancy. She reports a recent exposure to a child with chickenpox and is unsure of her immunity status. Which response by the nurse is most accurate?

A client at 9 weeks gestation by ultrasound presents with vaginal bleeding described as “grape-like clusters of tissue,” an hCG level markedly higher than expected for gestational age, a uterus larger than expected for dates, and absent fetal heart tones with a “snowstorm” pattern on ultrasound and no identifiable fetal parts. The nurse should anticipate preparation for which intervention, and what is the MOST important follow-up consideration?

A client at 36 weeks gestation with a known history of cocaine use during this pregnancy presents to the emergency department with sudden onset of severe, constant abdominal pain described as “tearing,” a uterus that is rigid and tender to palpation, and dark red vaginal bleeding. The fetal heart rate is sustained at 80 beats/min. The nurse recognizes this presentation as MOST consistent with which condition, and which finding would be considered a late, ominous sign if it develops?

A 26-year-old client’s Pap smear reveals high-grade squamous intraepithelial lesion (HSIL) with positive HPV 16. She becomes tearful and states, “I don’t understand—I feel completely fine, and I’ve had normal Pap smears my whole life.” Which statement by the nurse provides the most accurate education?

The nurse is preparing a client who is prescribed continuous epidural analgesia. Which of the following pre-procedure prescriptions should the nurse be prepared to administer?

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks’ gestation. What would be the priority problem for this neonate?

A client with confirmed endometriosis is scheduled for a laparoscopy. She asks the nurse why her pain is worse during menstruation and why she has had difficulty conceiving for 2 years. Which explanation by the nurse is most accurate?

The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina.  Place the following actions in the order in which they should be performed, starting from first to last. 1. Prepare the client for immediate cesarean delivery.2. Apply pressure to lift the presenting fetal part.3. Administer oxygen via face mask.4. Place the client in the Trendelenburg position.5. Stay with the client and call for help.