Nokea
A client at 28 weeks' gestation reports feeling fewer fetal movements. What should the nurse recommend first?
- A. Perform a nonstress test.
- B. Drink a glass of juice and lie down.
- C. Notify the healthcare provider immediately.
- D. Schedule an ultrasound.
Correct Answer: B
Rationale: Drinking juice and lying down can stimulate fetal movement and help evaluate whether further action is needed.
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What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.
Which data in the patient's history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?
- A. Previous depressive episode
- B. Unexpected operative birth
- C. Ambivalence during the first trimester
- D. Second pregnancy in a 3-year period
Correct Answer: A
Rationale: A previous history of depression is a significant risk factor for postpartum depression. Women who have experienced a depressive episode in the past are more likely to develop postpartum depression compared to those without such a history. Recognizing this pertinent data in the patient's history can help the nurse identify individuals at higher risk for postpartum depression and provide appropriate support and intervention. The other options mentioned (B. Unexpected operative birth, C. Ambivalence during the first trimester, D. Second pregnancy in a 3-year period) may also contribute to emotional distress but are not as directly linked to postpartum depression as a previous depressive episode.
The nurse is assessing a client with ruptured membranes. What finding suggests chorioamnionitis?
- A. Clear amniotic fluid.
- B. Foul-smelling vaginal discharge.
- C. Fetal heart rate of 140 beats/minute.
- D. Absence of maternal fever.
Correct Answer: B
Rationale: Foul-smelling discharge is a key indicator of chorioamnionitis, an infection of the amniotic fluid.
The nurse is educating a G1P0 client who is 34 weeks in the third trimester. gestation and in her third trimester. Which of the
- A. I should gain 3.5 to 5 pounds in the first following educational topics would be appropriate trimester and 1 pound per week in the last two at this time? Select all that apply. trimesters.
- B. Contraception options after delivery
- C. I should gain 10 pounds in the first trimester,
- D. Group B strep (GBS) screen before onset of labor 10 pounds in the second trimester, and 10 pounds
Correct Answer: A
Rationale: I should gain 3.5 to 5 pounds in the first trimester and 1 pound per week in the last two trimesters.
The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. New-onset confusion and restlessness.
- D. Urine output of 40 mL/hr.
Correct Answer: C
Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.