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, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
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A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
- A. Color of amniotic fluid.
- B. Maternal temperature.
- C. Deep tendon reflexes.
- D. Maternal blood pressure.
Correct Answer: B
Rationale: Prolonged ROM increases infection risk, necessitating frequent maternal temperature monitoring to detect chorioamnionitis early.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.
The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?
- A. Bolus of 2 ml/kg glucose 10% IV.
- B. Feed immediately.
- C. Echocardiogram.
- D. Monitor for respiratory distress.
- E. Apply dextrose gel inside the baby's cheek.
Correct Answer: E
Rationale: Applying dextrose gel is a rapid, non-invasive way to treat hypoglycemia, prioritizing immediate glucose stabilization in a jittery newborn.
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Yogurt.
- B. Whole milk.
- C. Collard greens.
- D. Strawberries.
Correct Answer: D
Rationale: Strawberries are a good source of folic acid, suitable for the client's dietary restrictions, unlike yogurt, milk, or collard greens, which either lack folic acid or are disliked.
History and Physical:
Laboratory Results:
The client is a 24-year-old pregnant woman. She is gravida 2, para 1 (G2P1). Her mother has a history of type 2 diabetes mellitus.
Which is likely causing this client's increased blood glucose at 28 weeks? Select all that is apply.
- A. Fetal health problems
- B. Decreased cortisol
- C. Increased insulin needs
- D. Placental infection
- E. Normal weight gain of pregnancy
- F. Fetus with macrosomia
Correct Answer: C,E,F
Rationale: Increased insulin needs, normal weight gain, and macrosomia contribute to insulin resistance and hyperglycemia in pregnancy, unlike fetal health issues, decreased cortisol, or placental infection.