Nursing practice questions with comprehensive rationales

Nursing Test Banks TEAS Test Banks TEAS Test Banks

NurseDive Free Nursing Practice Question

Take the full test now Share

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

A. Inspect the client's face for edema

Inspect the client's face for edema: Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

B. Ascertain the frequency of headaches

Ascertain the frequency of headaches: Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

C. Evaluate for history of cluster headaches

Evaluate for history of cluster headaches: Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

D. Observe and time client's contractions

Observe and time client's contractions: Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

This question is an excerpt from Nurse Dive's nursing test bank - Samuel Merrit University Oaklands Hesi Maternity (Labor and Delivery) Proctored Exam. Take the full exam now

Full Explanation

Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

Take a free test now Explore our nursing Q-bank

Full Explanation

Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.

Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.

Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.

Open full question → Take the full test now

QUESTION

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

A. Discuss options for intrauterine surgical correction of congenital defects.

At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.

B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.

While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.

C. Reassure the client that the AFP results are likely to be a false reading.

Reassure the client that the AFP results are likely to be a false reading: Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.

D. Explain that a sonogram should be scheduled for definitive results

Explain that a sonogram should be scheduled for definitive results:An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.

Full Explanation

A. Discuss options for intrauterine surgical correction of congenital defects:At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.

B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated:While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.

C. Reassure the client that the AFP results are likely to be a false reading: Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.

D. Explain that a sonogram should be scheduled for definitive results: An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.

Open full question → Take the full test now

QUESTION

The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer's Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number)

Full Explanation

To solve this problem, the nurse needs to convert the units of oxytocin from units to milliunits.

One unit of oxytocin is equal to 1000 milliunits, so 10 units of oxytocin is equal to 10,000 milliunits.

- The concentration of oxytocin in the solution is 10,000 milliunits per 1000 mL, or 10 milliunits per mL.

- To deliver 2 milliunits per minute, the nurse needs to infuse 0.2 mL per minute of the solution.

- To convert from mL per minute to mL per hour, the nurse needs to multiply by 60 minutes per hour.

- Therefore, the nurse should program the infusion pump to deliver 0.2 x 60 = 12 mL per hour of the solution.

Open full question → Take the full test now

Nursing practice questions with comprehensive rationales

NurseDive Free Nursing Practice Question

Full Explanation

Similar Questions

Full Explanation

Full Explanation

Full Explanation