Nokea
A client who is 30 weeks pregnant comes into the labor and delivery unit complaining of having a gush of fluid come from her vagina. Which complication is this client at risk for?
- A. Infection
- B. Fluid volume deficit
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client experiences a gush of fluid from the vagina at 30 weeks, it could indicate premature rupture of membranes (PROM) or preterm premature rupture of membranes (PPROM). This increases the risk of amniotic fluid leakage, leading to a decrease in the fluid surrounding the fetus. This can result in a fluid volume deficit for the fetus, potentially leading to complications such as fetal distress or preterm labor. In contrast, choices A, C, and D are less likely in this scenario. Infection (choice A) could be a risk later if the membranes are ruptured for an extended period. Hypotension (choice C) and decreased urinary output (choice D) are not directly related to the gush of fluid and are less likely in this immediate situation.
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A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
- A. Blood pressure of 155/95
- B. Urinary output is greater than 30 mL/hr
- C. Deep tendon reflexes +2
- D. Client complains of blurred vision
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A blood pressure of 155/95 indicates hypertension, a key feature of worsening pre-eclampsia. Hypertension in pre-eclampsia can lead to serious complications like eclampsia. High blood pressure can put the client at risk for seizures, stroke, and organ damage.
Incorrect choices:
B: Urinary output > 30 mL/hr is a positive sign, indicating adequate renal function, which is desirable in pre-eclampsia.
C: Deep tendon reflexes +2 are within normal limits and do not necessarily indicate worsening pre-eclampsia.
D: Blurred vision is a common symptom of pre-eclampsia but not a definitive sign of worsening condition.
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
- A. Having high levels of hCG
- B. Having high blood pressure
- C. Being an adolescent
- D. Being underweight
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.
A nurse is caring for a client who is 32 weeks gestation who comes to the emergency department for painful bleeding. Which is the priority nursing assessment?
- A. Monitor for contractions
- B. Assess pain level
- C. Assess for hemorrhage
- D. Provide emotional support
Correct Answer: C
Rationale: The correct priority nursing assessment in this scenario is to assess for hemorrhage (Choice C). This is crucial because painful bleeding in a client at 32 weeks gestation could indicate a potential life-threatening situation such as placental abruption or placenta previa. Assessing for hemorrhage involves checking the amount and type of bleeding, vital signs, and signs of shock. It is essential to identify and address hemorrhage promptly to prevent adverse outcomes for both the mother and the baby.
Monitoring for contractions (Choice A) is important but assessing for hemorrhage takes precedence due to the immediate risk it poses. Assessing the pain level (Choice B) is secondary to assessing for hemorrhage in this case. Providing emotional support (Choice D) is important but should come after ensuring the client's physical well-being is addressed.
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
The nurse is assessing a client who has been diagnosed with gestational diabetes. Which should the nurse monitor closely because of her diagnosis?
- A. Edema
- B. Blood pressure, pulse, and respiration
- C. Urine for glucose and ketones
- D. Hemoglobin and hematocrit
Correct Answer: C
Rationale: The correct answer is C: Urine for glucose and ketones. In gestational diabetes, monitoring urine for glucose and ketones is crucial to assess blood sugar control and ketosis. Glucose in urine indicates hyperglycemia, and ketones indicate inadequate insulin and potential ketoacidosis. Monitoring edema (choice A) is not specific to gestational diabetes. Blood pressure, pulse, and respiration (choice B) are important but not specific to gestational diabetes. Monitoring hemoglobin and hematocrit (choice D) does not directly reflect blood sugar control in gestational diabetes.