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A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding may indicate a serious condition called preeclampsia, characterized by high blood pressure and protein in the urine, posing risks to both the mother and baby. Reporting this promptly allows for timely management and monitoring.
Incorrect choices:
B: Varicose veins in the calves are common in pregnancy due to increased blood volume and pressure on veins, usually not an urgent concern.
C: Nonpitting 1+ ankle edema is a mild swelling often seen in pregnancy, which is typically expected and not alarming at this stage.
D: Hyperpigmentation of the cheeks, known as melasma or "mask of pregnancy," is a common cosmetic change in pregnancy, not requiring immediate medical attention.
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A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates a lack of uterine tone, which can lead to postpartum hemorrhage. Administering oxytocin helps to stimulate contractions, restoring uterine tone and reducing bleeding. Excess vaginal bleeding is also an indication for oxytocin as it helps to control bleeding by promoting uterine contractions. Choices B, D, and the remaining options do not directly relate to the need for oxytocin administration in postpartum care. A cervical laceration would require appropriate wound management, and increased afterbirth cramping may not necessarily warrant oxytocin administration unless coupled with other signs of uterine atony.
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 as it helps to monitor the baby's heart rate in response to its movements, providing crucial information about fetal well-being. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, helping to assess the baby's overall health and response to stimuli. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can decrease blood flow to the baby and is not recommended. Instructing the client to massage the abdomen (C) may artificially stimulate fetal movements, affecting the accuracy of the test results.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice A) is more relevant for labor assessment. Completing a sterile speculum exam (choice C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice D) is used to assess for rupture of membranes, not for applying an external transducer.
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: Correct Answer: B - Leakage of fluid from the vagina
Rationale: Following an amniocentesis at 18 weeks of gestation, leakage of fluid from the vagina could indicate a potential complication such as premature rupture of membranes. This complication could lead to preterm labor and pose a risk to both the mother and the fetus.
Summary of Other Choices:
A: Increased fetal movement - Normal fetal movement is expected following an amniocentesis and does not necessarily indicate a complication.
C: Upper abdominal discomfort - Common after an amniocentesis due to the needle insertion but usually resolves without major issues.
D: Urinary frequency - Not directly related to complications following an amniocentesis at 18 weeks gestation.