Nokea
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings what actions the nurse implement.
- A. Notify the healthcare provider of the finding
- B. Document the finding in the medical record
- C. Schedule the client for a biophysical profile
- D. Request another nurse measure the fundus
Correct Answer: A
Rationale: Fundal height greater than expected may indicate a complication, so notifying the healthcare provider (A) is necessary.
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A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
- A. Raise the foot of the bed
- B. Assess for vaginal bleeding
- C. Evaluate the fetal heart rate
- D. Take the client's blood pressure
Correct Answer: A
Rationale: These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the silent is in a lateral position are also appropriate interventions.
The traditional diet of Asian women includes little meat and few dairy products and may be low in calcium and iron. The nurse can assist a patient increase her intake of these foods by which action?
- A. Suggest that she eat more tofu, bok choy, and broccoli.
- B. Suggest that she eat more hot foods during pregnancy.
- C. Emphasize the need for increased milk intake during pregnancy.
- D. Tell her husband that she must increase her intake of fruits and vegetables for the baby's sake.
Correct Answer: A
Rationale: Rationale:
A: Tofu, bok choy, and broccoli are rich sources of calcium and iron, suitable for Asian diets low in these nutrients.
B: Eating hot foods during pregnancy does not specifically address increasing intake of calcium and iron.
C: Traditional Asian diets often do not emphasize milk consumption, and not all individuals can digest milk well.
D: Fruits and vegetables are important but not specific sources of calcium and iron. Also, dietary changes should be made by the individual, not someone else.
At the present time, which agency governs surrogate parenting?
- A. State law
- B. Federal law
- C. Individual court decision
- D. Protective child services
Correct Answer: C
Rationale: Surrogacy cases are decided individually in court, as there is no overarching state or federal law governing surrogacy.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicated that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record?
- A. 3-1-2-0-3
- B. 4-1-2-0-3
- C. 2-1-2-1-2
- D. 3-1-1-0-3
Correct Answer: D
Rationale: (D) describes the correct GTPAL. The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children.
A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, MENOPUR®), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately?
- A. Episodes of headache and irritability
- B. Nausea and vomiting
- C. Rapid increase in abdominal girth
- D. Persistent daytime fatigue
Correct Answer: C
Rationale: Rapid abdominal girth increase (C) may indicate ovarian hyperstimulation syndrome, a serious complication.