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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During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?
- A. Tachycardia
- B. Absence of clonus
- C. Polyuria
- D. Report of headache
Correct Answer: D
Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.
A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
- A. Apply warm, moist heat to the client's lower extremities.
- B. Massage the client's posterior lower legs.
- C. Place pillows under the client's knees when resting in bed.
- D. Have the client ambulate.
Correct Answer: D
Rationale: The correct intervention for a client who is 2 hours postpartum following a cesarean birth with a history of thromboembolic disease is to have the client ambulate. Early ambulation is crucial in preventing complications such as deep vein thrombosis in postpartum clients. Applying warm, moist heat, massaging the legs, or placing pillows under the knees do not directly address the risk of thromboembolic disease in this scenario.
When caring for a newborn with macrosomia born to a mother with diabetes mellitus, which newborn complication should the nurse prioritize care for?
- A. Hypoglycemia
- B. Hypomagnesemia
- C. Hyperbilirubinemia
- D. Hypocalcemia
Correct Answer: A
Rationale: In newborns of diabetic mothers with macrosomia, hypoglycemia is the priority focus of care due to the risk of developing low blood sugar levels after birth. Infants born to diabetic mothers are at risk of hypoglycemia because they have been exposed to high glucose levels in utero and produce high levels of insulin. Hypoglycemia can lead to serious complications if not promptly identified and managed, making it crucial for nurses to closely monitor blood glucose levels and provide necessary interventions to prevent adverse outcomes.
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 who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?
- A. The client is carrying more than one fetus
- B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid
- C. An excessive amount of amniotic fluid is present
- D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor
Correct Answer: C
Rationale: Polyhydramnios refers to the presence of an excessive amount of amniotic fluid around the fetus. This condition can result from various causes, such as maternal diabetes, fetal anomalies, or genetic disorders. It can lead to complications during pregnancy and delivery, such as preterm labor, placental abruption, or fetal malpresentation. Understanding this diagnosis is crucial for providing appropriate care and monitoring to ensure the best outcomes for both the mother and the fetus.