Nokea
A client who is 24 weeks gestation arrives at the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next?
- A. Review the client's previous blood pressures in the chart.
- B. Obtain the client's blood pressure.
- C. Observe and time the client's contractions.
- D. Examine the client for pedal edema.
Correct Answer: B
Rationale: Swollen hands and rapid weight gain could be signs of preeclampsia, so the next step is to check the client's blood pressure. Elevated blood pressure is a key indicator in assessing for preeclampsia in pregnancy. Reviewing the client's previous blood pressures may provide additional context but obtaining the current blood pressure is crucial for immediate assessment. Observing and timing contractions are not relevant in this scenario as the client is not presenting with signs of active labor. Examining for pedal edema is important in assessing for fluid retention, but obtaining the blood pressure takes precedence in this case due to the potential seriousness of preeclampsia.
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What additional assessment is required for the postoperative care of a pregnant woman who undergoes abdominal surgery for appendicitis?
- A. Intake and output (I&O) and intravenous (IV) site.
- B. Signs and symptoms of infection.
- C. Vital signs and incision.
- D. Fetal heart rate (FHR) and uterine activity.
Correct Answer: D
Rationale: The correct additional assessment for postoperative care of a pregnant woman requiring abdominal surgery for appendicitis is monitoring the fetal heart rate (FHR) and uterine activity. This is crucial due to the presence of the fetus. Continuous fetal and uterine monitoring should be prioritized to ensure the well-being of both the mother and the baby. While assessing I&O levels and the IV site are common postoperative care procedures, they are not specific to the unique needs of a pregnant woman. Evaluating for signs and symptoms of infection is important for any postoperative patient but is not the additional assessment required specifically for a pregnant woman in this scenario. Routine vital signs and incision evaluation are standard components of postoperative care but do not address the specific needs related to the fetus and the uterus in this case.
What is the purpose of amniocentesis?
- A. To induce abortion
- B. To detect genetic abnormalities in the fetus
- C. To determine the baby's gender
- D. To monitor fetal growth
Correct Answer: B
Rationale: Amniocentesis is a diagnostic procedure used to detect genetic abnormalities in the fetus, such as chromosomal disorders like Down syndrome. It is not performed to induce abortion. The primary purpose of amniocentesis is to assess the genetic health of the fetus, not to determine the baby's gender (Choice C). While amniocentesis can provide information about the baby's health and development, it is not primarily used for monitoring fetal growth (Choice D). Therefore, the correct answer is B.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which finding indicates that preterm labor is occurring?
- A. Estriol is not found in maternal saliva.
- B. Irregular, mild uterine contractions occur every 12 to 15 minutes.
- C. Fetal fibronectin is present in vaginal secretions.
- D. The cervix is effacing and dilated to 2 cm.
Correct Answer: D
Rationale: The correct answer is D. Cervical changes such as effacement and dilation to 2 cm are strong indicators of imminent preterm labor. These changes, combined with regular contractions, can signify labor at any gestation. Estriol can be detected in maternal plasma as early as 9 weeks of gestation. Levels of salivary estriol have been linked to preterm birth. Irregular, mild contractions occurring every 12 to 15 minutes without cervical change are generally not concerning. While the presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation may predict preterm labor, its predictive value is limited (20%-40%). Therefore, cervical changes provide more reliable information regarding the risk of preterm labor.
A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes. The nurse observes several shallow small vesicles on her pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition?
- A. Genital Warts
- B. Syphilis
- C. Herpes Simplex Virus
- D. German Measles
Correct Answer: C
Rationale: The correct answer is C: Herpes Simplex Virus (HSV). HSV can present with small vesicles on the genital area, and it is a concern during labor due to the risk of transmission to the newborn. Genital warts (Choice A) are caused by the human papillomavirus (HPV) and typically present as flesh-colored growths, not vesicles. Syphilis (Choice B) manifests as painless sores and can have systemic effects but does not typically present with vesicles. German measles (Choice D), also known as Rubella, is a viral illness characterized by a red rash, fever, and lymphadenopathy, not vesicles.
Jill bears the genetic code for Von Willebrand disease, but she has never developed the illness herself. Jill would be considered:
- A. a carrier of the recessive gene that causes the disease.
- B. susceptible to the disease after adolescence.
- C. an acceptor of the recessive gene that causes the disease.
- D. susceptible to the disease in late adulthood.
Correct Answer: A
Rationale: Jill is a carrier of the recessive gene for Von Willebrand disease. Being a carrier means that she has one copy of the gene but does not show symptoms of the disease. Carriers can pass on the gene to their offspring. Choice B is incorrect as being a carrier does not mean she is susceptible to developing the disease after adolescence. Choice C is incorrect as 'acceptor' is not a term used in genetics in this context. Choice D is incorrect as susceptibility to the disease is not related to late adulthood in carriers of a recessive gene.