Nokea
A client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?
- A. The client is carrying more than one fetus
- B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid
- C. An excessive amount of amniotic fluid is present
- D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor
Correct Answer: C
Rationale: Polyhydramnios refers to the presence of an excessive amount of amniotic fluid around the fetus. This condition can result from various causes, such as maternal diabetes, fetal anomalies, or genetic disorders. It can lead to complications during pregnancy and delivery, such as preterm labor, placental abruption, or fetal malpresentation. Understanding this diagnosis is crucial for providing appropriate care and monitoring to ensure the best outcomes for both the mother and the fetus.
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When admitting a client at 33 weeks of gestation with a diagnosis of placenta previa, which action should the nurse prioritize?
- A. Monitor vaginal bleeding
- B. Administer glucocorticoids
- C. Insert an IV catheter
- D. Apply an external fetal monitor
Correct Answer: D
Rationale: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to potential bleeding. When admitting a client with placenta previa, the priority is to assess the fetal well-being. Applying an external fetal monitor helps in continuous monitoring of the fetal heart rate and ensures timely detection of any distress or changes in the fetal status, which is crucial in managing this condition. While monitoring vaginal bleeding is important, identifying fetal well-being takes precedence in this situation.
A client is being assessed for postpartum infection. Which of the following findings should indicate to the healthcare provider that the client requires further evaluation for endometritis?
- A. Localized area of breast tenderness
- B. Pelvic pain
- C. Vaginal discharge with foul odor
- D. Hematuria
Correct Answer: B
Rationale: Pelvic pain is a common symptom of endometritis, which is an infection of the uterine lining. It is an important finding that warrants further evaluation. Localized area of breast tenderness may indicate mastitis, vaginal discharge with a foul odor could suggest a vaginal infection, and hematuria points towards a urinary tract issue, but they are not specific to endometritis.
A healthcare provider is preparing to administer an injection of Rho (D) immunoglobulin. The provider should understand that the purpose of this injection is to prevent which of the following newborn complications?
- A. Hydrops fetalis
- B. Hypobilirubinemia
- C. Biliary atresia
- D. Transient clotting difficulties
Correct Answer: B
Rationale: Rho (D) immunoglobulin is given to Rh-negative individuals to prevent hemolytic disease of the newborn (HDN) caused by Rh incompatibility between the mother and the fetus. If an Rh-negative mother carries an Rh-positive fetus, there is a risk of sensitization during pregnancy or childbirth. Sensitization can lead to the production of antibodies that may attack Rh-positive red blood cells in future pregnancies, potentially causing severe hemolytic disease in the newborn, including complications like hydrops fetalis. Hydrops fetalis is a condition characterized by severe edema and fetal organ enlargement due to severe anemia and heart failure in the fetus.
A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hours ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hours ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation
Correct Answer: A
Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.
When caring for a newborn with macrosomia born to a mother with diabetes mellitus, which newborn complication should the nurse prioritize care for?
- A. Hypoglycemia
- B. Hypomagnesemia
- C. Hyperbilirubinemia
- D. Hypocalcemia
Correct Answer: A
Rationale: In newborns of diabetic mothers with macrosomia, hypoglycemia is the priority focus of care due to the risk of developing low blood sugar levels after birth. Infants born to diabetic mothers are at risk of hypoglycemia because they have been exposed to high glucose levels in utero and produce high levels of insulin. Hypoglycemia can lead to serious complications if not promptly identified and managed, making it crucial for nurses to closely monitor blood glucose levels and provide necessary interventions to prevent adverse outcomes.