Nokea
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: Administering antiretroviral drugs as ordered. This is crucial in preventing vertical transmission of HIV from mother to child during childbirth. Antiretroviral therapy reduces the viral load in the mother's blood and bodily fluids, decreasing the risk of transmission. Choice B is beneficial for labor progress but not directly related to HIV care. Choice C is unnecessary as HIV is not transmitted through skin contact. Choice D is contraindicated as breastfeeding can transmit HIV from mother to child.
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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 may indicate pulmonary edema. This condition occurs due to fluid accumulation in the lungs, leading to symptoms like coughing. The increased blood volume and pressure during pregnancy can exacerbate the client's existing heart condition, resulting in pulmonary edema. Orthopnea (choice A) is difficulty breathing when lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not typically associated with a nonproductive cough. Decreased blood volume (choice D) would not directly lead to a nonproductive cough on minimal exertion.
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications.
Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.
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 recommended for women with a history of preterm birth due to cervical incompetency. Progesterone helps to reduce the risk of another preterm birth by supporting the cervix and preventing it from opening too early. It is important for the nurse to discuss the action and side effects of progesterone with the patient to ensure informed decision-making.
Choice A is incorrect as an abdominal ultrasound is not directly related to managing cervical incompetency. Choice B is incorrect as positioning the patient on her left side does not address the issue of cervical incompetency. Choice D is also incorrect as monitoring blood pressure is not the primary intervention for managing cervical incompetency in this case.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: Rationale for correct answer (A): Changing cat litter exposes the woman to Toxoplasma gondii, a parasite associated with chorioamnionitis. It is a known risk factor as the infection can spread to the fetus.
Summary of incorrect choices:
B (Frequent vaginal examination during labor): This does not directly increase the risk of chorioamnionitis.
C (Gestational diabetes): While gestational diabetes can have other complications, it is not a direct risk factor for chorioamnionitis.
D (Preterm premature rupture of the membranes): While this can increase the risk of infection, it is not a specific risk factor for chorioamnionitis.
A nurse is caring for a client who is G1P0 and 36 weeks gestation who has been diagnosed with severe pre-eclampsia. Her blood pressure is 165/110. The physician has ordered hydralazine. The nurse knows she should do which of the following when administering this medication?
- A. Position the client supine with the head of the bed elevated 30 degrees.
- B. Get baseline blood pressure and pulse and monitor frequently during administration.
- C. Administer medication every 5 minutes until blood pressure is stabilized.
- D. Inform the client that this may cause a positive direct Coombs test result.
Correct Answer: B
Rationale: The correct answer is B. The nurse should get baseline blood pressure and pulse and monitor frequently during administration to assess the effectiveness and safety of the medication. This is crucial in managing severe pre-eclampsia.
Choice A is incorrect because the client should be positioned on her left side to prevent vena cava compression, not supine with the head of the bed elevated.
Choice C is incorrect because administering medication every 5 minutes without proper monitoring can lead to adverse effects like hypotension.
Choice D is incorrect because hydralazine does not cause a positive direct Coombs test result. It is important for the nurse to provide accurate information to the client.