Nokea
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.
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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 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 with severe hyperemesis gravidarum. She is 10 weeks gestation and has a 10% weight loss. The client is being admitted for fluid and electrolyte replacement. The nurse is aware it is important to check which deficiency that puts the client at risk for Wernicke’s encephalopathy?
- A. Folic acid
- B. Vitamin D
- C. Thiamine
- D. Glucose
Correct Answer: C
Rationale: The correct answer is C: Thiamine. Thiamine deficiency can lead to Wernicke’s encephalopathy in patients with severe hyperemesis gravidarum due to poor nutrient absorption and inadequate dietary intake. This condition can cause neurological symptoms like confusion and ataxia. Folic acid (A) deficiency is common in pregnancy but is not directly related to Wernicke's encephalopathy. Vitamin D (B) deficiency is associated with bone health and immune function, not neurological symptoms. Glucose (D) is important for energy production but is not directly linked to Wernicke's encephalopathy. Checking thiamine levels is crucial to prevent neurological complications in this client.
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 at higher risk for hyperemesis gravidarum due to hormonal changes and inadequate nutritional intake. Adolescents often experience rapid growth and increased nutritional demands, leading to a higher susceptibility to conditions like hyperemesis gravidarum. High levels of hCG (A) are common in pregnancy and can contribute to nausea and vomiting but are not the primary cause of hyperemesis gravidarum. High blood pressure (B) is not directly related to hyperemesis gravidarum. Being underweight (D) may exacerbate the condition but is not the primary factor causing hyperemesis gravidarum in this case.
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
- A. Prepare the woman for an abdominal ultrasound
- B. Place the patient on her left side to increase perfusion to the fetus
- C. Be prepared to discuss the action and side effects of progesterone
- D. Monitor the patient’s blood pressure closely
Correct Answer: C
Rationale: The correct answer is C because progesterone is a recommended treatment for cervical incompetency to prevent preterm birth. Progesterone helps support the uterine lining and decrease the risk of preterm labor. Therefore, discussing the action and side effects of progesterone with the patient is essential.
A: While an abdominal ultrasound may provide information about the cervix, it is not the immediate priority in this case.
B: Placing the patient on her left side is a common practice for improving blood flow, but it is not directly related to managing cervical incompetency.
D: Monitoring blood pressure is important in prenatal care, but it is not specifically related to the management of cervical incompetency in this context.