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 carbohydrates such as cereal
...
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 carbohydrates 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
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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
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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
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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
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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
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