Nokea
The nurse is caring for a client with a suspected hydatidiform mole. Based on the diagnosis, what does the nurse anticipate? Select all that apply.
- A. Dark brown vaginal bleeding
- B. Strong fetal heart tones
- C. Fundal height larger than expected
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Strong fetal heart tones. In a hydatidiform mole, the pregnancy is abnormal and does not involve a fetus. Therefore, the absence of fetal heart tones is expected. Dark brown vaginal bleeding (A) is not specific to a hydatidiform mole. Fundal height larger than expected (C) and elevated blood pressure (D) are not typically associated with a hydatidiform mole.
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The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
- A. Administering antiretroviral drugs as ordered
- B. Assisting the woman on a labor ball to help with natural descent of the fetus
- C. Handling the newborn with gloves until it receives its first bath
- D. Encouraging the mother to breastfeed soon after delivery
Correct Answer: A
Rationale: The correct answer is A because administering antiretroviral drugs as ordered helps reduce the risk of vertical transmission of HIV from mother to baby during childbirth. This treatment is essential in managing the client's HIV status and ensuring the safety of the newborn.
Choice B is incorrect because using a labor ball does not directly address the HIV status of the client or the transmission risk to the newborn.
Choice C is incorrect as wearing gloves when handling the newborn does not replace the need for antiretroviral therapy to prevent transmission.
Choice D is incorrect because breastfeeding can transmit HIV from mother to baby, so it is not recommended for HIV-positive mothers to breastfeed.
The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick showing protein of 3+ indicates significant proteinuria, a sign of preeclampsia in pregnancy. Preeclampsia can lead to serious complications for both the mother and the baby, such as eclampsia and fetal growth restriction. The nurse should further assess the client's blood pressure, perform additional tests for preeclampsia, and closely monitor the client's condition.
Choice A: Hemoglobin and hematocrit levels are within normal range for pregnancy and do not require immediate intervention.
Choice B: Blood pressure of 130/80 is slightly elevated but not concerning at this gestational age. Close monitoring is recommended.
Choice C: Slight pedal swelling is common in pregnancy due to fluid retention and usually does not indicate a serious issue.
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 for hyperglycemia and ketosis, which can indicate poor blood sugar control. This helps in adjusting the treatment plan and preventing complications.
A: Edema is not directly related to gestational diabetes and is more commonly associated with conditions like heart failure or kidney disease.
B: Monitoring blood pressure, pulse, and respiration is important in general health assessment but not specific to gestational diabetes.
D: Hemoglobin and hematocrit levels are important for monitoring anemia, but not directly related to gestational diabetes management.
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.