NC1 SET 4

Postpartum day 3, a client has BP 166/110, severe headache, and blurred vision. What is the first nursing action?

• Institute seizure precautions and start magnesium per protocol

• Obtain a 24-hour urine collection for protein quantification

• Encourage oral fluids and reassess symptoms later

• Prepare oxytocin infusion for expedited uterine involution

A laboring client on magnesium sulfate becomes somnolent with RR 8/min, absent reflexes, and urine 15 mL/hr. What is the priority?

• Stop magnesium, give calcium gluconate per protocol, and support ventilation

• Increase magnesium rate to prevent seizures from recurring

• Restrict all fluids and wait for a spontaneous recovery

• Administer an opioid for comfort and observe for improvement

Immediately after birth, the uterus is firm and midline, but bleeding is brisk and bright red. What is the best nursing interpretation?

• Genital tract laceration likely; prepare for examination and repair

• Uterine atony likely; begin high-dose uterotonics immediately

• Bladder distention likely; perform immediate catheterization

• Retained placenta likely; prepare for manual removal now

During labor, a client develops sudden hypoxia, hypotension, and DIC without warning. What is the priority nursing response?

• Call a code, deliver high-flow oxygen, support circulation, and activate massive transfusion protocol

• Place the client in Trendelenburg and await spontaneous recovery

• Administer a diuretic to reduce pulmonary edema risk

• Provide oral fluids while arranging a chest radiograph

A 31-week client has preterm labor with intact membranes and no infection. Which nursing actions are appropriate now? Select all that apply.

• Arrange antenatal corticosteroids for fetal lung maturity

• Consider tocolysis to allow completion of the steroid course

• Begin routine digital cervical examinations every hour

• Obtain GBS screen and avoid unnecessary vaginal exams

• Discharge home with strict bed rest and no medications

Post-cesarean day 1, a client has pleuritic chest pain, tachycardia, and SpO₂ 90%. What is the first nursing action?

• Apply oxygen, elevate the head, notify provider, and prepare for diagnostic imaging

• Encourage brisk ambulation to mobilize the suspected clot

• Massage the calf to improve venous return and comfort

• Offer oral fluids and reassess oxygen saturation later

A TOLAC client on low-dose oxytocin reports sudden tearing pain between contractions with vaginal bleeding and loss of station. What is the priority?

• Encourage active pushing to restore fetal descent

• Stop oxytocin and call an obstetric emergency immediately

• Start amnioinfusion to relieve variable decelerations

• Obtain a urine ketone test to rule out dehydration

A postpartum client with asthma has uterine atony after oxytocin. Which nursing actions are appropriate now? Select all that apply.

• Perform bimanual massage and ensure bladder emptying

• Administer misoprostol per rectum as ordered

• Give tranexamic acid within 3 hours of birth if not contraindicated

• Administer carboprost IM despite the asthma history

• Prepare uterine balloon tamponade if bleeding persists

A 35-week client has intense nocturnal pruritus of palms and soles; bile acids return at 60 μmol/L. What is the best nursing plan today?

• Notify the provider, support symptom therapy, arrange fetal surveillance, and discuss delivery timing near 36-37 weeks

• Reassure that itching is benign and continue routine prenatal care

• Begin magnesium sulfate prophylaxis to reduce seizure risk

• Delay all surveillance because fetal risk is minimal at this stage

Six weeks postpartum after GDM, a client asks about diabetes follow-up. What is the most accurate teaching?

• A random glucose today is sufficient to exclude diabetes long term

• Schedule a 75-g OGTT at 4-12 weeks postpartum and screen every 1-3 years thereafter

• Discontinue all screening because insulin needs ended after delivery

• Use home capillary checks only when symptoms of diabetes appear