Saunders Online Review Focus on Maternity Rated A

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: A Eat foods high in calories and fat B Lie down for at least 20 min ...

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: A Eat foods high in calories and fat B Lie down for at least 20 minutes after meals C Eat carbohydrates such as cereals, rice, and pasta Correct D Consume primarily soups and liquids at mealtimes Incorrect
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 (4th ed., pp. 589-590). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points.
2.ID: 9476908110A 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? A Clonus is present. B Magnesium level is 10 mg/dL (4.11 mmol/L) C Deep tendon reflexes are absent. D The client experiences diuresis within 24 to 48 hours. Correct
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 (4th ed., pp. 594-595). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476908130A 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: A Vitamin K B Protamine sulfate C Calcium gluconate Correct D Naloxone hydrochloride
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 (31st ed., p. 773). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476908194A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? A Milk B Steak C Chicken D Lima beans Correct
Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the best source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review the foods high in folic acid 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: Nutrition
Giddens Concepts: Nutrition, Reproduction
HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 282-283). St. Louis: Elsevier.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 114, 119). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476904403A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: A Avoid the use of shampoo on the infant’s scalp B Apply oil to the affected area on the infant’s scalp Correct C Wash the infant’s scalp daily, using only tepid water D Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation.
Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed-ended word “only.” To select from the remaining options, recall that this condition is characterized by the presence of scaly lesions; this will direct you to the correct option. Review the treatment for seborrheic dermatitis (cradle cap) 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: Newborn
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 467-468). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
6.ID: 9476901633A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: A Documents the findings B Contacts the health care provider C Administers 100% oxygen by way of face mask D Instructs the client to take several deep breaths Correct