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A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?
- A. Notify child protective services of the client's illicit drug use and probable child endangerment.
- B. Praise the client for her actions and offer to discuss ways to decrease consumption even more.
- C. Refer the client to an outpatient alcohol abuse program for disulfiram therapy.
- D. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.
Correct Answer: B
Rationale: Praising reduced alcohol intake encourages further reduction, while offering support fosters a collaborative approach to minimize fetal alcohol exposure.
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A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation.
- A. She may be experiencing postpartum preeclampsia.
- B. She may have an infection that needs further evaluation.
- C. Her symptoms could indicate anemia due to blood loss.
- D. She may be experiencing normal postpartum fatigue.
Correct Answer: A
Rationale: Symptoms like headache, visual disturbances, and nausea suggest postpartum preeclampsia, unlike infection, anemia, or normal fatigue, which don't typically include these signs.
The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?
- A. Bolus of 2 ml/kg glucose 10% IV.
- B. Feed immediately.
- C. Echocardiogram.
- D. Monitor for respiratory distress.
- E. Apply dextrose gel inside the baby's cheek.
Correct Answer: E
Rationale: Applying dextrose gel is a rapid, non-invasive way to treat hypoglycemia, prioritizing immediate glucose stabilization in a jittery newborn.
A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
- A. Obtain a blood glucose level.
- B. Feed the infant glucose water (10%).
- C. Administer oxygen.
- D. Decrease environmental stimuli.
Correct Answer: A
Rationale: Obtaining a blood glucose level confirms hypoglycemia as the cause of jitteriness, common in LGA infants of diabetic mothers, guiding treatment.
History and Physical:
Nurses' Notes:
Vital Signs:
Laboratory Results:
The client is a 28-year-old primiparous female who was induced at 41 weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock.
A nurse is caring for a primiparous client in the postpartum unit. The client was induced at 41 weeks gestation with misoprostol and oxytocin and gave birth vaginally 4 days ago. She was discharged home on day two with her newborn and has been breastfeeding around the clock. She called her healthcare provider this morning with fatigue, new-onset headache, nausea, dizziness, weakness, and seeing "flashing lights."
The nurse reviews the client's history, physical, and flow sheet to determine the cause of the client's symptoms. Highlight the information from the history, physical, and flow sheet that require further evaluation. Select all that apply.
- A. Hemoglobin 10.4 g/dL (6.45 mmol/L)
- B. Platelets 150,000/mm³ (150 x 10â¹/L)
- C. New-onset headache
- D. Vomiting small amount of yellow fluid
- E. Right upper quadrant pain
- F. Seeing flashing lights
- G. Elevated blood pressure
Correct Answer: C,D,E,F,G
Rationale: Headache, vomiting, right upper quadrant pain, flashing lights, and elevated blood pressure suggest postpartum preeclampsia or HELLP syndrome, requiring urgent evaluation.