Nokea
The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history?
- A. Maternal diabetes
- B. Weight gain of 25 lb
- C. Maternal age older than 30 years
- D. Previous infant weighing more than 3000 g at birth
Correct Answer: A
Rationale: The correct answer is A, maternal diabetes. Maternal diabetes increases the risk of fetal anomalies, so fetal diagnostic procedures may be indicated for early detection. Weight gain, maternal age over 30, and previous infant weight do not necessarily indicate a need for fetal diagnostic procedures. Weight gain and older age are common in pregnancy, while the previous infant's weight alone is not a direct indicator of fetal health.
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What does optimal nursing care after an amniocentesis include?
- A. Pushing fluids by mouth
- B. Monitoring uterine activity
- C. Placing the patient in a supine position for 2 hours
- D. Applying a pressure dressing to the puncture site
Correct Answer: B
Rationale: The correct answer is B: Monitoring uterine activity. After an amniocentesis, it is crucial to monitor uterine activity to detect any signs of preterm labor or uterine contractions. This helps in identifying any potential complications early on and ensures prompt intervention if needed.
A: Pushing fluids by mouth is important for hydration but not directly related to optimal nursing care after an amniocentesis.
C: Placing the patient in a supine position for 2 hours is not recommended as it may increase the risk of hypotension and discomfort for the patient.
D: Applying a pressure dressing to the puncture site is not necessary after an amniocentesis as the risk of bleeding is minimal and pressure dressings may increase the risk of infection.
The nurse has identified the following nursing diagnosis for a postpartum (PP) client: Potential for fluid volume deficit. Which of the following goals for the mother is appropriate?
- A. Minimal perineal pain.
- B. Normal lochial flow.
- C. Normal temperature.
- D. Weight reduction.
Correct Answer: B
Rationale: Normal lochial flow indicates that the client is not experiencing excessive bleeding, which is a key concern for fluid volume deficit.
A client with type 1 diabetes mellitus is 6 weeks pregnant. Her fasting glucose and hemoglobin A1C are noted to be 168 mg/dL and 12%, respectively. Which of the following nursing diagnoses is appropriate for the nurse to make at this time?
- A. Altered maternal skin integrity.
- B. Deficient maternal fluid volume.
- C. Risk for fetal injury.
- D. Fetal urinary retention.
Correct Answer: C
Rationale: The high glucose levels and elevated A1C indicate poor glycemic control, which poses a risk for fetal injury due to potential complications like macrosomia or congenital anomalies.
A nurse has just inserted an orogastric gavage tube into a preterm baby. When would the nurse determine that the tube is in the proper location?
- A. When gastric aspirate is removed from the tube.
- B. When the baby suckles on the tubing.
- C. When respirations are unlabored during tube insertion.
- D. When the tubing can be inserted no farther.
Correct Answer: A
Rationale: The presence of gastric aspirate confirms that the tube is in the stomach, which is the proper location for feeding.
A woman, who is in pain from a diagnosis of mastitis, has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following?
- A. Mammary rupture.
- B. Postpartum psychosis.
- C. Supernumerary nipples.
- D. Breast abscess.
Correct Answer: D
Rationale: Abrupt weaning can lead to milk stasis, increasing the risk of a breast abscess due to bacterial infection.