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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During a prenatal visit, a pregnant woman says, 'I know the amniotic fluid is important, but can you tell me more about it?' When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include?
- A. This fluid acts as a cushion to help protect your baby from injury.
- B. The amount of fluid remains fairly constant throughout the pregnancy.
- C. The fluid is mostly protein to provide nourishment to your baby.
- D. This fluid acts as a transport mechanism for oxygen and nutrients.
Correct Answer: A
Rationale: Amniotic fluid cushions the fetus against injury, aiding movement and growth. Its volume varies (peaks at term), is mostly water (not protein), and doesn't transport oxygen or nutrients, which the placenta handles.
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 nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.
- A. Nausea
- B. Abdominal enlargement
- C. Positive pregnancy test
- D. Braxton Hicks contractions
- E. Amenorrhea
Correct Answer: A,B,C,E
Rationale: Presumptive signs, subjective or non-definitive, include nausea (hormonal), abdominal enlargement (uterine growth), positive pregnancy test (hCG detection), and amenorrhea (missed periods). Braxton Hicks are probable signs, felt later.
A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions?
- A. Cervical insufficiency
- B. Uterine fibroids
- C. Fetal genetic abnormalities
- D. Maternal disease
Correct Answer: C
Rationale: Fetal genetic abnormalities, like chromosomal errors, cause ~70% of first trimester abortions. Cervical insufficiency affects later trimesters, fibroids and maternal diseases (e.g., diabetes) are less common causes early on.
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.