Nokea
A 22-year-old homeless woman arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment a 12-week gestational uterus, a BP of 110/70, a BMI of 17.5. The client admits to using cocaine a few times. She has been pregnant before and indicates she 'loses them early.' What characteristics place the client in the high-risk pregnancy category? Select all that apply.
- A. Homelessness
- B. Age
- C. BP 110/70
- D. BMI 17.5
- E. Prenatal care
- F. Prenatal history
Correct Answer: A,D,E,F
Rationale: Homelessness increases risks via poor nutrition and stress; BMI 17.5 indicates malnutrition; lack of prenatal care raises complication risks; prior losses suggest underlying issues. Age (22) is optimal, and BP 110/70 is normal, not risks.
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A nurse suspects that a pregnant client may be experiencing placenta abruption based on which finding? Select all that apply.
- A. Absence of pain
- B. Insidious onset
- C. Dark red vaginal bleeding
- D. Rigid uterus
- E. Absent fetal heart tones
Correct Answer: C,D,E
Rationale: Placental abruption involves sudden separation of the placenta, causing severe pain, a rigid uterus from bleeding, dark red vaginal bleeding due to clotted blood, and absent fetal heart tones if the fetus is compromised. Absence of pain and insidious onset are not typical, as abruption is acute and painful.
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
- A. Difficulty in arousing
- B. Deep tendon reflexes 2+
- C. Urinary output of 30 mL per hour
- D. Respiratory rate of 10 breaths/minute
Correct Answer: B
Rationale: Deep tendon reflexes at 2+ indicate a therapeutic magnesium level, preventing seizures without toxicity. Difficulty arousing, low urinary output (below 40 mL/hr), or respiratory rate of 10 suggest toxicity, requiring intervention.
Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?
- A. Ferrous sulfate
- B. Potassium chloride
- C. Calcium carbonate
- D. Calcium gluconate
Correct Answer: D
Rationale: Calcium gluconate reverses magnesium toxicity (e.g., respiratory depression), a risk with magnesium sulfate used for preeclampsia. Ferrous sulfate treats anemia, potassium chloride corrects hypokalemia, and calcium carbonate is an antacid, none addressing toxicity.
Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of which condition?
- A. Maternal diabetes
- B. Fetal anencephaly
- C. Placental abruption
- D. Neural tube defects
Correct Answer: B
Rationale: Oligohydramnios (low amniotic fluid) is linked to fetal anencephaly, where absent brain development reduces fetal urine, a fluid source. Maternal diabetes causes polyhydramnios, abruption affects bleeding, and neural tube defects don't directly reduce fluid.
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating:
- A. Hemoconcentration by hypertension
- B. A multiple gestation pregnancy
- C. Greater-than-expected weight gain
- D. Iron-deficiency anemia
Correct Answer: D
Rationale: A hemoglobin of 11 g/dL is low for the second trimester (10.5-14 g/dL), suggesting iron-deficiency anemia, especially with symptoms like fatigue. Hemoconcentration raises hemoglobin, multiple gestation lowers it slightly, and weight gain is unrelated.