Nokea
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL)
- B. A client who is at 34 weeks of gestation and reports epigastric pain
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL)
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
Correct Answer: B
Rationale: The correct answer is B: A client who is at 34 weeks of gestation and reports epigastric pain. This client should be identified as the priority because epigastric pain in pregnancy can be a sign of preeclampsia, a serious condition that requires immediate attention to prevent maternal and fetal complications. Preeclampsia is characterized by high blood pressure and protein in the urine, and it can lead to seizures (eclampsia) if not managed promptly. The other clients have issues that are important but not as urgent as potential preeclampsia. Client A's blood glucose level is elevated but not critically high, Client C's hemoglobin level is slightly low but not acutely life-threatening, and Client D's symptoms of urinary frequency and dysuria are common in late pregnancy and do not indicate a medical emergency.
You may also like to solve these questions
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A. At 26 weeks of gestation, newborns are expected to have minimal arm recoil based on the New Ballard Score, as their muscle tone is typically low. This indicates immaturity and aligns with the developmental stage of a premature infant. The other choices are incorrect because: B: A popliteal angle of 90° is more indicative of a term infant. C: Creases over the entire foot sole are also seen in term infants, not premature infants. D: Raised areolas with 3 to 4 mm buds are associated with breast development in term infants, not preterm infants.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
Correct Answer: A
Rationale: The correct answer is A: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy can be a sign of ectopic pregnancy, miscarriage, or other complications requiring immediate attention. The nurse should see this client first to assess the situation and provide appropriate interventions.
Choice B is incorrect because tingling and numbness in the right hand is not typically an urgent issue in pregnancy. Choice C is incorrect as constipation, while uncomfortable, is not an immediate concern that requires urgent attention. Choice D is incorrect as bloody noses can be common in pregnancy due to increased blood volume and nasal congestion, but it does not require immediate attention unless severe or persistent.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. In a client with peripartum cardiomyopathy, monitoring blood pressure is crucial to detect worsening heart function and potential complications. Assessing blood pressure twice daily allows for early detection of hypertension or hypotension, which can indicate cardiac decompensation. Misoprostol (Choice A) is not indicated in this scenario. Restricting fluid intake (Choice C) can lead to dehydration and worsen the client's condition. Administering an IV bolus of lactated Ringer's (Choice D) may not be appropriate without assessing the client's fluid status first.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (A). Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.