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A client with type 1 diabetes mellitus is 6 weeks pregnant. Her fasting glucose and hemoglobin A1C are noted to be 168 mg/dL and 12%, respectively. Which of the following nursing diagnoses is appropriate for the nurse to make at this time?
- A. Altered maternal skin integrity.
- B. Deficient maternal fluid volume.
- C. Risk for fetal injury.
- D. Fetal urinary retention.
Correct Answer: C
Rationale: The high glucose levels and elevated A1C indicate poor glycemic control, which poses a risk for fetal injury due to potential complications like macrosomia or congenital anomalies.
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The nurse receives a phone call from a patient concerned about the results of the laboratory tests obtained at the first prenatal visit 10 days ago. What is the nurse's next action?
- A. ask the patient if they have checked their electronic chart
- B. inform the patient they will need to wait until the next office visit for the results
- C. provide the patient with the results of the tests
- D. verify the identification of the patient
Correct Answer: D
Rationale: The correct answer is D: verify the identification of the patient. This is crucial to ensure patient safety and confidentiality. By verifying the patient's identity, the nurse can confirm they are providing the correct information to the right person, preventing potential errors or breaches of confidentiality. Asking about the electronic chart (A) is unnecessary if the identity is not confirmed. Informing the patient to wait (B) does not address the immediate concern. Providing results (C) without proper identification can lead to miscommunication. Hence, verifying the patient's identification is the first step to address the patient's concerns effectively.
What is the purpose of initiating contractions in a contraction stress test (CST)?
- A. Increase placental blood flow.
- B. Identify fetal acceleration patterns.
- C. Determine the degree of fetal activity.
- D. Apply a stressful stimulus to the fetus.
Correct Answer: D
Rationale: The purpose of initiating contractions in a contraction stress test (CST) is to apply a stressful stimulus to the fetus to assess its response to stress, mimicking the stress of labor. This helps evaluate fetal well-being by monitoring the fetal heart rate during contractions. A: Increasing placental blood flow is not the primary purpose of CST. B: Identifying fetal acceleration patterns is not the main goal of CST. C: Determining the degree of fetal activity is not the primary objective of CST. The correct answer is D as it reflects the main purpose of initiating contractions in a CST.
A breastfeeding mother and her baby are being discharged home after delivery. The nurse is providing anticipatory guidance about what signs to expect the baby to exhibit every 24 hours by the end of the first week. Which of the following should the nurse include in his/her instructions?
- A. The baby will have at least 6 wet diapers.
- B. The baby will have at least 6 pasty stools.
- C. The baby will breastfeed at least 6 times.
- D. The baby will gain at least 6 ounces.
Correct Answer: A
Rationale: Adequate wet diapers indicate proper hydration and milk intake.
A pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient's plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: The correct answer is B: Refer to the physician for additional testing. When a triple-screen test is positive in a pregnant patient, it indicates an increased risk of certain conditions such as neural tube defects or chromosomal abnormalities. Therefore, the appropriate course of action is to refer the patient to a physician for further diagnostic testing, such as amniocentesis or ultrasound, to confirm or rule out these conditions.
Choice A is incorrect because a positive result on a triple-screen test does not indicate that results are normal; it suggests the need for further investigation. Choice C is incorrect because validating the results with the lab facility does not address the need for additional diagnostic testing. Choice D is incorrect because waiting 2 weeks to repeat the test and returning for a regular prenatal visit may delay necessary interventions or treatment for the patient.
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.