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A client at 37 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Preeclampsia.
- B. Cholestasis of pregnancy.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: B
Rationale: The correct answer is B: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 37 weeks' gestation is concerning for cholestasis of pregnancy, a condition characterized by impaired bile flow. This can lead to elevated bile acids, causing itching. Preeclampsia (choice A) presents with hypertension and proteinuria. Gestational diabetes (choice C) manifests with high blood sugar levels. Fungal infection (choice D) typically presents with visible skin changes like a rash, which is absent in this case. In summary, cholestasis of pregnancy is the most likely explanation for severe itching in this scenario.
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The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.
The nurse is educating a client about folic acid during pregnancy. What food should the nurse recommend?
- A. Citrus fruits.
- B. Leafy green vegetables.
- C. Dairy products.
- D. Lean meats.
Correct Answer: B
Rationale: The correct answer is B: Leafy green vegetables. Folic acid is essential during pregnancy for proper fetal development. Leafy green vegetables like spinach, kale, and broccoli are rich sources of folic acid. Citrus fruits (Choice A) contain vitamin C but not as much folic acid as leafy greens. Dairy products (Choice C) provide calcium but are not significant sources of folic acid. Lean meats (Choice D) are good sources of protein but do not contain as much folic acid as leafy green vegetables. Therefore, recommending leafy green vegetables ensures the client gets an adequate intake of folic acid during pregnancy.
A nurse is assessing a newborn who was born Post term. Which of the following findings should the nurse expect?
- A. A Rh-negative mother who has an Rh- positive infant
- B. A Rh "“positive mother who has an Rh- negative infant
- C. A Rh-positive mother who has an Rh- positive infant
- D. A Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: A Rh-negative mother who has an Rh-positive infant. Post-term infants are at higher risk for conditions such as Rh incompatibility. Since the mother is Rh-negative and the infant is Rh-positive, there is a potential for Rh incompatibility, leading to hemolytic disease of the newborn. This occurs when the mother's antibodies attack the infant's red blood cells.
Choice B is incorrect because Rh incompatibility occurs when the mother is Rh-negative and the infant is Rh-positive. Choice C is incorrect as both mother and infant being Rh-positive do not lead to Rh incompatibility. Choice D is incorrect because Rh incompatibility does not occur when both mother and infant are Rh-negative.
The nurse is preparing a client for a biophysical profile (BPP). What does this test evaluate?
- A. Maternal blood flow to the placenta.
- B. Fetal genetic abnormalities.
- C. Fetal well-being, including movements and amniotic fluid.
- D. Cervical dilation and effacement.
Correct Answer: C
Rationale: The correct answer is C: Fetal well-being, including movements and amniotic fluid. A Biophysical Profile evaluates the fetus' health by assessing factors like fetal movements, muscle tone, breathing movements, amniotic fluid volume, and fetal heart rate patterns. This test provides valuable information about the fetus' well-being and helps in determining the need for interventions or further monitoring.
Explanation of why the other choices are incorrect:
A: Maternal blood flow to the placenta is not evaluated by a Biophysical Profile.
B: Fetal genetic abnormalities are not assessed through a BPP; it focuses on the fetus' current well-being.
D: Cervical dilation and effacement are related to labor progress and not part of a BPP, which focuses on fetal well-being.
The nurse is monitoring a client with hypertonic uterine contractions. What is the priority nursing action?
- A. Administer pain relief as prescribed.
- B. Prepare for an amniotomy.
- C. Encourage ambulation.
- D. Increase oxytocin infusion.
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief as prescribed. The priority is to address the client's discomfort and pain caused by hypertonic uterine contractions. Pain management is crucial to ensure the client's comfort and well-being. Administering pain relief can help prevent complications such as increased stress on the mother and fetus.
Choice B: Prepare for an amniotomy is incorrect because it involves artificial rupturing of the amniotic sac, which is not indicated for hypertonic contractions.
Choice C: Encourage ambulation is incorrect because it may exacerbate the pain and discomfort experienced by the client with hypertonic uterine contractions.
Choice D: Increase oxytocin infusion is incorrect because it can further intensify the uterine contractions and worsen the client's pain.