Nokea
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?
- A. clear liquid diet
- B. administration of diethylstilbestrol
- C. total parenteral nutrition
- D. nothing by mouth
Correct Answer: C
Rationale: Hyperemesis gravidarum causes severe vomiting, risking dehydration and malnutrition. Total parenteral nutrition delivers complete nutrients intravenously, addressing these risks when oral intake fails. Clear liquids or nothing by mouth worsen malnutrition, and diethylstilbestrol, a discontinued drug, is irrelevant.
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A client's last menstrual period was April 11. Using Naegele's rule, her estimated date of birth (EDB) would be:
- A. 24-Feb
- B. 18-Jan
- C. 25-Jan
- D. 18-Feb
Correct Answer: B
Rationale: Nägele's rule: April 11, 2023 + 1 year = April 11, 2024; minus 3 months = January 11, 2024; plus 7 days = January 18, 2024. Other options incorrectly adjust months or days.
A nurse is preparing to infuse 1 liter of 0.9% sodium chloride IV over 8 hr with a tubing set that delivers 15 gtts/mL. The nurse should set the manual IV infusion to deliver how many drops/min?
- A. 31 gtts/min
- B. 30 gtts/min
- C. 32 gtts/min
- D. 29 gtts/min
Correct Answer: A
Rationale: Formula: gtts/min = (volume x drop factor) / time. (1000 mL x 15 gtts/mL) / (8 x 60 min) = 15000 / 480 = 31.25, rounded to 31 gtts/min. Other options miscalculate the rate.
A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?
- A. Wear spandex-type full-length pants
- B. Try elevating your legs when you sit
- C. Limit your intake of fluids
- D. Eliminate salt from your diet
Correct Answer: B
Rationale: Elevating legs reduces swelling by aiding venous return, a safe intervention for late-pregnancy edema. Tight pants worsen swelling, limiting fluids risks dehydration, and eliminating salt disrupts electrolytes.
A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply.
- A. Cloudy malodorous fluid
- B. Abdominal tenderness
- C. Fetal bradycardia
- D. Elevated maternal pulse rate
- E. Decreased C-reactive protein levels
Correct Answer: A,B,C,D
Rationale: Infection after membrane rupture shows as cloudy, foul fluid (bacterial contamination), abdominal tenderness (inflammation), fetal bradycardia (distress), and elevated pulse (systemic response). Decreased C-reactive protein doesn't indicate infection; it rises with inflammation.
A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would lead the nurse to suspect that the client is having an adverse effect associated with this drug?
- A. Gastrointestinal bleeding
- B. Sweating
- C. Tachycardia
- D. Blurred vision
Correct Answer: C
Rationale: Hydralazine, a vasodilator, can cause reflex tachycardia as blood pressure drops, increasing cardiac strain. Gastrointestinal bleeding, sweating, and blurred vision (a preeclampsia symptom) are not typical adverse effects.