Session 4 Exam 3 - Focus on Maternity Exam

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A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: Eat foods high in calories and fat Eat carbohyd... rates such as cereals, rice, and pasta Correct! Lie down for at least 20 minutes after meals Consume primarily soups and liquids at mealtimes 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 2/132 Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review measures to ease and prevent nausea and vomiting if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Fluid and Electrolytes, Nutrition HESI Concepts: Fluids and Electrolytes, Nutrition Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4 ed., pp. 589-590). St. Louis: Elsevier. th Ques 1 / 1 pts tion 2 A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 3/132 Clonus is present. Deep tendon reflexes are absent. The client experiences diuresis within 24 to 48 hours. Correct! Magnesium level is 10 mg/dL (4.11 mmol/L) Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent. Test-Taking Strategy: Use the process of elimination and focus on the strategic words “medication is effective.” Recalling the actions of this medication and expected assessment findings after a client receives magnesium sulfate will direct you to this option. Review the expected assessment findings for a client receiving magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Giddens Concepts: Evidence, Perfusion HESI Concepts: Evidence-Based Practice/Evidence, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4 ed., pp. 594-595). St. Louis: Elsevier. th 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 4/132 Ques 1 / 1 pts tion 3 A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: Calcium gluconate Correct! Protamine sulfate Naloxone hydrochloride Vitamin K 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 5/132 Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioidinduced respiratory depression. Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in directing you to the correct option. Review common antidotes if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31 ed., p. 773). St. Louis: Mosby [Show More]

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