Nokea
A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
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A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
- A. Intensity of pain with contraction.
- B. Fetal heart rate.
- C. Temperature, pulse, and respirations.
- D. Deep tendon reflexes and clonus.
Correct Answer: D
Rationale: Assessing deep tendon reflexes and clonus detects CNS irritability, critical for identifying severe preeclampsia and eclampsia risk.
The day shift nurse reviews the nurse's notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge health teaching. For each teaching point, indicate whether it is Indicated (appropriate or necessary) or Contraindicated (could be harmful). Each box must have one option selected.
- A. You will need to set up an appointment with your pediatrician for 3 weeks from discharge.
- B. The discharge planning nurse will set up home bilirubin lights for you to use until you see the pediatrician.
- C. You will need to set up an appointment with your obstetrician in 8 weeks.
Correct Answer: A,B,C
Rationale: A: Indicated - Pediatric check-ups at 2-4 weeks monitor newborn health. B: Indicated - Bilirubin lights treat jaundice, preventing complications. C: Contraindicated - Obstetrician visits are typically at 6 weeks, not 8.
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
- A. Preparation for emergency cesarean birth.
- B. Intensity, interval, and length of contractions.
- C. Checking the perineum for bulging.
- D. Client's hourly blood pressure.
Correct Answer: B
Rationale: Monitoring contraction patterns ensures oxytocin efficacy and prevents hyperstimulation in hypotonic dystocia, critical for labor progression.
A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?
- A. Passive immunity in the first months of life provides protection in newborns.
- B. Infants can receive antiinfectants that have not developed resistance to microbes.
- C. Active immunity in newborns is developed fully in the first month of life.
- D. Neutrophils may be immature in protecting neonates from the risk for infection.
Correct Answer: A
Rationale: Passive immunity from maternal antibodies provides newborns with initial protection against communicable diseases, lasting several months until their immune system matures.
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Shallow and irregular respirations.
- B. Flaring of the nares.
- C. Abdominal breathing with synchronous chest movement.
- D. Respiratory rate of 50 breaths per minute.
Correct Answer: B
Rationale: Nasal flaring indicates increased breathing effort, a sign of respiratory distress in newborns, unlike normal respiratory patterns.