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A client’s vital signs during labor and delivery were: BP 100/58–110/66, T 98.6ºF–98.8ºF, P 72–80 bpm, R 20–24 rpm. The client’s vitals 2 hours postpartum are BP 100/56, TPR 99.4ºF, P 70 bpm, R 20 rpm. Which of the following actions should the nurse perform at this time?
- A. Check the client’s lochia flow.
- B. Ask the client if she is having chills.
- C. Encourage the client to drink fluids.
- D. Assess the client’s lung fields.
Correct Answer: A
Rationale: Checking the client’s lochia flow is important to ensure there is no excessive bleeding, which could indicate postpartum hemorrhage.
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Which complaint made by a patient at 35 weeks of gestation requires additional assessment?
- A. Abdominal pain
- B. Ankle edema in the afternoon
- C. Backache with prolonged standing
- D. Shortness of breath when climbing stairs
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. This complaint at 35 weeks of gestation requires additional assessment as it could indicate a serious issue such as preterm labor, placental abruption, or other complications. Abdominal pain in late pregnancy should never be ignored. Ankle edema in the afternoon, backache with prolonged standing, and shortness of breath when climbing stairs are common discomforts in pregnancy and may not necessarily indicate a serious problem at this stage.
Which factors should be considered a contraindication for transcervical chorionic villus sampling?
- A. Rh-negative mother
- B. Gestation less than 15 weeks
- C. Maternal age younger than 35 years
- D. Positive for group B Streptococcus
Correct Answer: D
Rationale: The correct answer is D because being positive for group B Streptococcus can increase the risk of infection during transcervical chorionic villus sampling, making it a contraindication. Rh-negative mother (A) and maternal age younger than 35 years (C) are not contraindications. Gestation less than 15 weeks (B) is not a strict contraindication but may affect the accuracy of the procedure.
Which information is covered by early pregnancy classes offered in the first and second trimesters?
- A. Methods of pain relief
- B. The phases and stages of labor
- C. Coping with common discomforts of pregnancy
- D. Prebirth and postbirth care of a patient having a cesarean birth
Correct Answer: C
Rationale: The correct answer is C: Coping with common discomforts of pregnancy. Early pregnancy classes in the first and second trimesters focus on providing expecting mothers with strategies to manage common physical and emotional challenges during pregnancy. This includes information on dealing with nausea, fatigue, backaches, and emotional changes. Understanding and coping with these discomforts can help pregnant women have a more comfortable and healthy pregnancy.
A: Methods of pain relief are typically covered in childbirth preparation classes closer to the due date, not in early pregnancy classes.
B: The phases and stages of labor are usually discussed in depth in childbirth education classes taken later in pregnancy, not in early pregnancy classes.
D: Prebirth and postbirth care of a patient having a cesarean birth is a specific topic that may be covered in a separate class for women who are planning or have been recommended to have a cesarean birth, not typically in early pregnancy classes.
The nurse in the obstetrician’s office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor?
- A. African American, 15 years old, with newly diagnosed gestational diabetes.
- B. Asian American, 23 years old, with five-year-old twins who were born at term.
- C. Jewish, 25 years old, working as a certified public accountant.
- D. Mormon, 33 years old, who recently moved into a new apartment.
Correct Answer: A
Rationale: Young age and gestational diabetes are risk factors for preterm labor, making it important to educate this client.
The nurse is caring for a client and her partner who just birthed a 33-week fetal demise. Which of the following actions by the nurse is appropriate at this time?
- A. Recommend that the woman be moved to a medical unit.
- B. Refrain from discussing the loss with the couple.
- C. Ask the couple if they would like to hold their baby.
- D. Obtain an order for a milk suppressant for the mother.
Correct Answer: C
Rationale: Allowing the couple to hold their baby facilitates the grieving process and provides closure.