Nokea
A client who is 30 weeks pregnant comes into the labor and delivery unit complaining of having a gush of fluid come from her vagina. Which complication is this client at risk for?
- A. Infection
- B. Fluid volume deficit
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client experiences a gush of fluid from the vagina at 30 weeks, it could indicate premature rupture of membranes (PROM) or preterm premature rupture of membranes (PPROM). This increases the risk of amniotic fluid leakage, leading to a decrease in the fluid surrounding the fetus. This can result in a fluid volume deficit for the fetus, potentially leading to complications such as fetal distress or preterm labor. In contrast, choices A, C, and D are less likely in this scenario. Infection (choice A) could be a risk later if the membranes are ruptured for an extended period. Hypotension (choice C) and decreased urinary output (choice D) are not directly related to the gush of fluid and are less likely in this immediate situation.
You may also like to solve these questions
During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
- A. Orthopnea
- B. Pulmonary edema
- C. Anemia
- D. Decreased blood volume
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect suggests pulmonary edema. This is due to fluid accumulation in the lungs, leading to coughing. Pulmonary edema can occur due to increased blood volume and pressure on the heart during pregnancy, exacerbating the client's pre-existing heart condition. Orthopnea (choice A) is difficulty breathing while lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not directly linked to a nonproductive cough. Decreased blood volume (choice D) is unlikely in a pregnant client and would not explain the cough.
A nurse is monitoring a client with type 2 diabetes mellitus. Her blood work reveals a glycosylated hemoglobin (HbA1c) of 10%. The nurse knows this blood work indicates which of the following?
- A. A normal value indicating that the client is managing blood glucose control well
- B. A low value indicating that the client is not managing blood glucose control very well
- C. A high value indicating that the client is not managing blood glucose control very well
- D. The value does not offer information regarding client management of her disease
Correct Answer: C
Rationale: Rationale:
1. HbA1c reflects average blood glucose levels over the past 2-3 months.
2. A value of 10% indicates poor blood glucose control.
3. High HbA1c (like 10%) signifies uncontrolled diabetes.
4. Choice C is correct due to the high HbA1c value.
Summary:
A: Incorrect as 10% is high, not normal.
B: Incorrect, as 10% is high, not low.
D: Incorrect, as HbA1c does offer information regarding diabetes management.
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 reading of 3+ for protein indicates significant proteinuria, which can be a sign of preeclampsia in pregnancy. Preeclampsia poses serious risks to both the mother and the fetus, requiring immediate medical intervention.
Choice A: Hemoglobin and hematocrit levels within normal range for pregnancy.
Choice B: Blood pressure slightly elevated but not concerning at this gestational age.
Choice C: Slight pedal swelling is common in pregnancy and may not indicate a serious issue at this time.
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.
The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.