Nokea
Which of the following conditions is the client most likely developing?
- A. Pelvic inflammatory.
- B. Ectopic pregnancy.
- C. Pyclonephritis.
- D. C-reactive protein.
- E. Beta hCG.
- F. Urinalysis.
Correct Answer: A
Rationale: [1, 0, 0, 0, 0, 0]
The correct answer is A: Pelvic inflammatory. Pelvic inflammatory disease is an infection of the female reproductive organs, often caused by sexually transmitted infections. It presents with symptoms like pelvic pain, abnormal vaginal discharge, and fever. Ectopic pregnancy (B) is the implantation of a fertilized egg outside the uterus and presents with abdominal pain and vaginal bleeding. Pyelonephritis (C) is a kidney infection, typically causing fever and flank pain. C-reactive protein (D) is a marker for inflammation and infection, not a specific condition. Beta hCG (E) is a hormone produced in pregnancy. Urinalysis (F) is a test to analyze urine composition, not a condition.
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A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs.
- B. Swelling of feet and ankles at the end of the day.
- C. Headache that is unrelieved by analgesia.
- D. Braxton Hicks contractions.
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a potentially serious condition such as preeclampsia, which requires immediate medical attention to prevent complications for the mother and baby. Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is expected in pregnancy due to increased fluid retention. Braxton Hicks contractions (D) are normal and not a cause for concern unless they become regular and closer together.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to track fetal movement and heart rate patterns. By pressing the button each time fetal movement is felt, the nurse can correlate these movements with any changes in the fetal heart rate, providing valuable information about fetal well-being. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can reduce blood flow to the fetus and is not recommended. Instructing the client to massage the abdomen (C) may lead to inaccurate test results by artificially stimulating fetal movements.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. This finding could indicate an amniotic fluid leak, which is a potential complication following an amniocentesis. Amniotic fluid leakage can lead to infection and preterm labor. Increased fetal movement (choice A) is a normal sign of fetal well-being. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common after an amniocentesis and are not typically concerning unless severe or persistent.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate IV can cause toxicity leading to respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity as it antagonizes the effects of magnesium on the muscles. Having it readily available ensures prompt treatment in case of toxicity.
Restricting fluid intake (A) is not necessary for preeclampsia and can lead to dehydration. Assessing deep tendon reflexes (C) every 6 hours is important but not as crucial as having the antidote readily available. Monitoring intake and output (D) every 4 hours is important for overall assessment but does not directly address magnesium sulfate toxicity.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.