A nurse is caring for a client who is pregnant.

Complete the following sentence by using the lists of options.

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should first assist with is
_
followed by
_

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Reviewing fetal heart rate tracing: Reviewing the fetal heart rate tracing is the first action because the client has signs of severe preeclampsia, which can quickly lead to fetal distress. The fetal monitor will provide immediate information about the baby’s oxygenation status. Detecting any late decelerations or bradycardia would require urgent intervention to protect fetal life.
Administering IM betamethasone: Administering IM betamethasone is important to accelerate fetal lung maturity in case early delivery is necessary. Since the client is only at 31 weeks, promoting lung development is crucial to improve neonatal outcomes. However, confirming fetal well-being comes first before giving medications.
Scheduling an emergency cesarean section: An emergency cesarean section is not the first step without evidence of fetal compromise or maternal instability. At this point, the fetal heart rate shows moderate variability and accelerations, which are reassuring. A cesarean is only scheduled if fetal distress or worsening maternal condition occurs after further monitoring.
Insert a Foley catheter to monitor urine output: Inserting a Foley catheter is important to monitor kidney function and fluid status in preeclampsia. Reduced urine output can signal worsening disease. However, it is not the priority over assessing the fetal condition first, because fetal distress can occur rapidly and needs immediate identification.
Administering antibiotics: There is no current indication for administering antibiotics based on the client's data. The client does not have signs of infection, such as fever, elevated WBCs, or positive urinalysis for infection. Administering antibiotics would not address the current primary risks related to severe preeclampsia.

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Correct Answer is A

Explanation

A. Flight of ideas: Flight of ideas is a classic finding in clients experiencing a manic episode of bipolar disorder. It is characterized by rapid, continuous shifts from one topic to another, often making it difficult for the listener to follow the conversation. This reflects the elevated mood and pressured speech typical of mania.

B. Ritualistic behavior: Ritualistic behaviors, such as repetitive actions or strict routines, are more commonly associated with obsessive-compulsive disorder (OCD) rather than bipolar disorder. While clients with bipolar disorder may show disorganized behavior during mania, ritualism is not a hallmark feature.

C. Well-groomed appearance: During manic or depressive episodes of bipolar disorder, clients often experience a decline in self-care and grooming. A consistently well-groomed appearance would be more typical of a stable, euthymic phase rather than during an active mood episode.

D. Command hallucinations: Command hallucinations are typically linked to psychotic disorders such as schizophrenia. Although severe mania can include psychotic features, hallucinations are not a primary or consistent symptom in bipolar disorder unless it becomes a psychotic manic or depressive episode.

A. Hyperbilirubinemia B. Hyperemesis gravidarum C. Iron deficiency anemia D. Neural tube defects

Correct Answer is D

Explanation

A. Hyperbilirubinemia: Hyperbilirubinemia in neonates is commonly due to immature liver function and the breakdown of red blood cells after birth. It is not linked to maternal folic acid deficiency and would not be prevented through maternal folic acid supplementation.

B. Hyperemesis gravidarum: Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs during pregnancy, affecting the mother rather than the neonate. Folic acid supplementation does not prevent this condition, as it is more related to hormonal changes during pregnancy.

C. Iron deficiency anemia: Iron deficiency anemia occurs when there is an inadequate amount of iron, not folic acid, in the mother’s or infant’s diet. While iron is important during pregnancy for both the mother and the developing fetus, folic acid deficiency primarily affects neural tube development, not iron levels or red blood cell production in the same way. Iron supplementation is recommended during pregnancy to prevent iron deficiency anemia.

D. Neural tube defects: Neural tube defects, such as spina bifida and anencephaly, are directly linked to folic acid deficiency during early pregnancy. Adequate folic acid intake before conception and during early pregnancy significantly reduces the risk of these serious birth defects affecting the brain and spine.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a group of clients about taking recommended folic acid supplements prior to conception and throughout pregnancy as primary prevention. Which of the following conditions can occur in the neonate as the result of folic acid deficiency?

Correct Answer is D

Explanation

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

A nurse is preparing to transfer a client who is non-weight bearing from the bed to a chair with the aid of an assistive personnel. The client is cooperative and has upper body strength. Which of the following assistive devices should the nurse use when transferring the client?

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply)