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After reviewing the information provided in the client's medical record, which of the following complications should the nurse identify that the client is at risk of developing?
- A. Preeclampsia; uric acid
- B. Gestational diabetes; glucose
- C. Eclampsia; magnesium
- D. Placenta previa; hemoglobin
Correct Answer: B
Rationale: Gestational diabetes risk is linked to glucose intolerance, detectable by serum glucose levels, causing complications like macrosomia. Preeclampsia involves hypertension, not uric acid alone; eclampsia isn't tied to magnesium levels; placenta previa relates to prior surgeries, not hemoglobin.
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It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
- A. 24 hours before delivery and 24 hours after delivery
- B. In the first trimester and within 2 hours of delivery
- C. At 28 weeks gestation and again within 72 hours after delivery
- D. At 32 weeks gestation and immediately before discharge
Correct Answer: C
Rationale: Rho(D) immune globulin at 28 weeks and within 72 hours post-delivery prevents Rh isoimmunization by neutralizing fetal Rh-positive cells. Earlier or later timing risks ineffective prevention or antibody formation.
Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
- A. Recurrent pelvic infections
- B. Ovarian cyst 2 years ago
- C. Use of oral contraceptives for 8 years
- D. Heavy, irregular periods
Correct Answer: A
Rationale: Recurrent pelvic infections (e.g., PID) scar fallopian tubes, increasing ectopic pregnancy risk by hindering egg transport. Ovarian cysts, oral contraceptives (which reduce risk), and irregular periods don't directly contribute.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
- A. I'm sorry you lost your baby.
- B. Why are you crying?
- C. Will a pill help your pain?
- D. A baby still wasn't formed in your womb.
Correct Answer: A
Rationale: Saying 'I'm sorry you lost your baby' acknowledges the client's emotional loss empathetically. Asking why she's crying invalidates her feelings, focusing on physical pain ignores emotional needs, and claiming the baby wasn't formed is inaccurate and insensitive, as miscarriage involves loss at any stage.
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as
- A. linea nigra
- B. pica
- C. ballottement
- D. quickening
Correct Answer: B
Rationale: Pica is the craving for non-food items like ice, often linked to nutrient deficiencies such as iron. Linea nigra is a skin line, ballottement is a fetal palpation technique, and quickening is feeling fetal movement, none related to cravings.
When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
- A. Ambivalence
- B. Emotional lability
- C. Introversion
- D. Acceptance
Correct Answer: B
Rationale: Emotional lability, with mood swings, is common in the first trimester due to hormonal shifts and stress. Ambivalence may occur if unplanned, introversion is a trait, and acceptance develops later.