Nokea
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
- A. Provide oral hydration
- B. Have a complete blood count (CBC) drawn
- C. Obtain a specimen for urine analysis
- D. Place the client on strict bedrest
Correct Answer: C
Rationale: Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.
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A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
- A. Patient has lost 30 lb during the 6-week period prior to her scheduled checkup.
- B. Patient states that she is eating healthy and limiting intake of processed foods.
- C. Patient relates increased consumption of fruits and vegetables in her diet postbirth.
- D. Patient has resumed her usual exercise pattern of walking around the neighborhood for 10 minutes each night.
Correct Answer: A
Rationale: The correct answer is (A) because losing 30 lb in the 6-week postpartum period is concerning as it is excessive and may indicate underlying health issues like hyperthyroidism or inadequate nutrition. This rapid weight loss can also affect the mother's energy levels, milk production, and overall health.
Choice (B) is incorrect as eating healthy and limiting processed foods is a positive behavior that supports weight management. Choice (C) is also incorrect as increased consumption of fruits and vegetables is beneficial for overall health. Choice (D) is incorrect because resuming a light exercise routine like walking is generally encouraged postpartum, as long as it is done safely and does not lead to excessive strain.
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometer
- B. Review maternal medical records for blood type and Rh factor
- C. Prepare the newborn for phototherapy
- D. Evaluate cord results
Correct Answer: A
Rationale: Measuring bilirubin levels (A) is the first step to determine if phototherapy is necessary for jaundice.
A client at 38-weeks gestation is admitted to the labor and delivery unit with mild contractions every 5 minutes. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
- A. Monitor the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Encourage the client to ambulate.
- D. Administer pain medication.
Correct Answer: A
Rationale: Monitoring the fetal heart rate pattern after membrane rupture is essential to detect any changes in fetal status.
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.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.