Nokea
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. She has had a prior pregnancy with pregnancy-induced hypertension. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. Based on the client's past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic?
- A. Headaches.
- B. Blood glucose level.
- C. Proteinuria.
- D. Edema in lower extremities.
Correct Answer: C
Rationale: Proteinuria is a key indicator of preeclampsia, distinguishing it from gestational hypertension.
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A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which of the following hormones?
- A. Progesterone.
- B. Estrogen.
- C. Somatotropin.
- D. Aldosterone.
Correct Answer: B
Rationale: High estrogen levels are associated with hyperemesis gravidarum.
After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following?
- A. As my child grows, she may have increased fatigue and difficulty breathing.'
- B. My child may need to have antibiotics if she develops an infection.'
- C. This condition occurs more commonly in females than in males.'
- D. About half of the children born with this defect heal spontaneously.'
Correct Answer: C
Rationale: Atrial septal defects are not significantly more common in females, indicating a need for further instruction.
A client asks about the benefits of a hormonal IUD. Which of the following would the nurse include?
- A. It provides protection against STIs.
- B. It can reduce menstrual bleeding over time.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with heavy periods.
Correct Answer: B
Rationale: A hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against STIs, lasts 3-7 years, and is suitable for heavy periods.
The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?
- A. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n.
- B. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n.
- C. Colace 100 mg P.O. b.i.d.
- D. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.
Correct Answer: B
Rationale: Ibuprofen is safe for breastfeeding mothers and effective for uterine cramping pain, unlike aspirin (risk of bleeding), Colace (stool softener), or Vicodin (opioid, less preferred due to sedation risks).