Nokea
A client who was seen in the prenatal clinic at 20 weeks’ gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks’ gestation?
- A. 129 to 130 lb.
- B. 131 to 132 lb.
- C. 133 to 134 lb.
- D. 135 to 136 lb.
Correct Answer: C
Rationale: A weight gain of 1 lb per week is expected during the second and third trimesters. Therefore, the client should gain approximately 4 lb between 20 and 24 weeks.
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Which of the following is the most appropriate nursing action for a patient who has been administered an epidural block and is now experiencing hypotension?
- A. Administer a bolus of IV fluids
- B. Place the patient in a Trendelenburg position
- C. Administer oxygen via mask
- D. Raise the head of the bed slightly
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. Hypotension after an epidural block is often due to vasodilation caused by the block. Administering IV fluids can help increase blood volume and improve blood pressure. This action is crucial in maintaining perfusion to vital organs.
Choice B: Placing the patient in a Trendelenburg position can potentially worsen hypotension by increasing venous return to the heart, leading to further vasodilation and reduced blood pressure.
Choice C: Administering oxygen via mask may be important in some situations but is not the primary intervention for hypotension caused by epidural block.
Choice D: Raising the head of the bed slightly is not the best option for treating hypotension as it does not address the underlying cause of vasodilation and decreased blood pressure.
A nurse is caring for a laboring person in the first stage of labor. What is the priority assessment during this stage?
- A. assess fetal heart rate
- B. monitor contractions
- C. administer oxytocin
- D. check for cervical dilation
Correct Answer: A
Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring fetal well-being is the priority to ensure the baby's safety. Assessing the fetal heart rate helps determine if the baby is tolerating labor well. Monitoring contractions (B) is important but assessing the fetal heart rate takes precedence. Administering oxytocin (C) should be done based on specific indications and not as a routine assessment during the first stage of labor. Checking for cervical dilation (D) is important but does not take priority over assessing fetal well-being.
A woman delivers a fetal demise that has lanugo covering the entire body, nails that are present on the fingers and toes, but eyes that are still fused. Prior to the death, the mother stated that she had felt quickening. Based on this information, the nurse knows that the baby is about how many weeks’ gestation?
- A. 15 weeks.
- B. 22 weeks.
- C. 29 weeks.
- D. 36 weeks.
Correct Answer: B
Rationale: Lanugo typically appears around 16-20 weeks and covers the entire body by 22-24 weeks. Nails begin forming at around 18-20 weeks and are fully developed by 22 weeks. Fused eyelids occur up until about 24-26 weeks, after which they open. Quickening (feeling of fetal movement) usually occurs between 18-22 weeks in first-time pregnancies. Therefore, the most likely gestational age is 22 weeks.
The nurse is caring for a pregnant patient who has a BMI of 30. Which of the following complications is the patient at increased risk for during pregnancy?
- A. Preeclampsia and gestational diabetes
- B. Hyperemesis gravidarum and miscarriage
- C. Iron-deficiency anemia and urinary tract infections
- D. Gestational hypertension and placenta previa
Correct Answer: A
Rationale: The correct answer is A: Preeclampsia and gestational diabetes. A pregnant patient with a BMI of 30 is considered obese, increasing the risk of developing preeclampsia and gestational diabetes. Obesity is a known risk factor for these complications due to the increased strain on the body's systems. Preeclampsia is characterized by high blood pressure and protein in the urine, which can lead to serious complications for both the mother and the baby. Gestational diabetes is a type of diabetes that develops during pregnancy and can lead to complications for both the mother and the baby if not managed properly. The other choices (B, C, D) are not directly associated with obesity or a BMI of 30 during pregnancy, making them incorrect.
What is true about the morula stage of development?
- A. Fertilized egg has yet to implant
- B. Lung fields are completely formed
- C. Sex of fetus can be identified
- D. Eyelids begin to open and close
Correct Answer: A
Rationale: The morula stage occurs before implantation, representing an early phase of embryonic development.