Nokea
A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?
- A. Perform effleurage during contractions.
- B. Place the client in lithotomy position.
- C. Assist the client to the hands and knees position.
- D. Apply a scalp electrode to the fetus.
Correct Answer: C
Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.
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When caring for clients in a prenatal clinic, a nurse should report which client's weight gain to the provider?
- A. 1.8 kg (4 lb) weight gain in the first trimester
- B. 3.6 kg (8 lb) weight gain in the first trimester
- C. 6.8 kg (15 lb) weight gain in the second trimester
- D. 11.3 kg (25 lb) weight gain in the third trimester
Correct Answer: B
Rationale: The correct answer is B: 3.6 kg (8 lb) weight gain in the first trimester. This amount of weight gain in the first trimester is higher than the recommended range of 1.1-4.5 lbs. It could indicate potential issues such as gestational diabetes or preeclampsia. Choices A, C, and D fall within or closer to the expected weight gain ranges for each trimester, making them less concerning. Reporting excessive weight gain early allows for timely intervention and monitoring.
A woman in a women's health clinic is receiving teaching about nutritional intake during her 8th week of gestation. The healthcare provider should advise the woman to increase her daily intake of which of the following nutrients?
- A. Calcium
- B. Vitamin E
- C. Iron
- D. Vitamin D
Correct Answer: C
Rationale: The correct answer is C: Iron. During pregnancy, the body's demand for iron increases to support the growing fetus and placenta. Iron is essential for the production of hemoglobin, which carries oxygen to the baby. Inadequate iron intake can lead to maternal anemia and complications. Calcium is important for bone health, but the focus in the 8th week of gestation should be on iron. Vitamin E is an antioxidant that is important for overall health but not specifically targeted for increased intake in the 8th week of pregnancy. Vitamin D is crucial for calcium absorption and bone health, but iron takes precedence during this stage of pregnancy.
A healthcare professional is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition?
- A. No alteration in menses
- B. Transvaginal ultrasound indicating a fetus in the uterus
- C. Blood progesterone greater than the expected reference range
- D. Report of severe shoulder pain
Correct Answer: D
Rationale: The correct answer is D: Report of severe shoulder pain. In a ruptured ectopic pregnancy, the fertilized egg implants outside the uterus, usually in the fallopian tube. As the tube ruptures, there is internal bleeding which can irritate the diaphragm, causing referred pain to the shoulder. This phenomenon is known as Kehr's sign. The other choices are incorrect because with a ruptured ectopic pregnancy, there would typically be altered menses due to the pregnancy disruption, a transvaginal ultrasound would not show a fetus in the uterus, and blood progesterone levels would not be elevated.
A client with hyperemesis gravidarum is receiving dietary teaching. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat foods that appeal to my taste instead of trying to balance my meals.
- B. I will avoid having a snack at bedtime.
- C. I will have 8 ounces of hot tea with each meal.
- D. I will pair my sweets with a starch instead of eating them alone.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Hyperemesis gravidarum causes severe nausea and vomiting during pregnancy, leading to poor appetite and weight loss.
2. Eating foods that appeal to taste can help the client consume more calories and nutrients.
3. Balancing meals may not be a priority during hyperemesis gravidarum as the focus is on maintaining adequate nutrition.
4. Choices B, C, and D do not directly address the client's nutritional needs or coping with hyperemesis gravidarum.
A client is postpartum and has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: Step 1: In idiopathic thrombocytopenic purpura (ITP), there is a decreased platelet count due to immune-mediated destruction of platelets.
Step 2: This leads to an increased risk of bleeding and bruising in the postpartum client.
Step 3: Other choices are incorrect because in ITP, there is no increase in ESR or WBC. Also, megakaryocytes may be normal or increased due to compensatory production.