Nokea
A client at 37 weeks of gestation with placenta previa asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
- A. There is an increased risk of introducing infection.
- B. This could initiate preterm labor.
- C. This could result in profound bleeding.
- D. There is an increased risk of rupture of the membranes.
Correct Answer: C
Rationale: Performing an internal examination in a client with placenta previa can lead to significant bleeding due to the proximity of the placenta to the cervical os. This bleeding can be severe and potentially life-threatening. Therefore, it is crucial to avoid any unnecessary manipulation that could disrupt the delicate balance and lead to hemorrhage.
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A client in a prenatal clinic is being taught by a nurse in her second trimester with a new diagnosis of gestational diabetes. Which of the following client statements indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will reduce my exercise schedule to 3 days a week.
- C. I will take my glyburide daily with breakfast.
- D. I know I am at increased risk of developing type 2 diabetes.
Correct Answer: B
Rationale: Choice B, 'I will reduce my exercise schedule to 3 days a week,' indicates a need for further teaching. Regular exercise is beneficial in managing gestational diabetes and should not be reduced without proper guidance. Choices A, C, and D demonstrate understanding and appropriate actions in managing gestational diabetes.
A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
- A. Recheck the client's temperature in 4 hours
- B. Administer glucocorticoids intramuscularly
- C. Assess the odor of the amniotic fluid
- D. Prepare the client for emergency cesarean section
Correct Answer: C
Rationale: In a pregnant woman with a temperature of 38.9°C (102°F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.
A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
- A. Administer oxygen via nasal cannula
- B. Offer option to view products of conception
- C. Instruct the client to increase potassium-rich foods in the diet
- D. Maintain the client on bed rest
Correct Answer: B
Rationale: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.
A client at 37 weeks of gestation with severe gestational hypertension is being admitted by a nurse. Which of the following actions should the nurse NOT expect to implement?
- A. Administer magnesium sulfate IV.
- B. Provide a dark, quiet environment.
- C. Assess respiratory status every 4 hours.
- D. Ensure that calcium gluconate is readily available.
Correct Answer: C
Rationale: Assessing respiratory status every 4 hours is not a priority for a client with severe gestational hypertension. In this scenario, the focus should be on monitoring blood pressure, assessing for signs of preeclampsia, administering medications like magnesium sulfate for seizure prophylaxis, and ensuring that calcium gluconate is readily available in case of magnesium toxicity. Respiratory status assessment is important in other conditions but is not directly related to managing severe gestational hypertension.
A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?
- A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions
- B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
- C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes
- D. A client who has a diagnosis of preeclampsia reports epigastric pain and an unresolved headache
Correct Answer: D
Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.