Nokea
A healthcare provider is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the provider expect? (Select all that apply)
- A. Chadwick's sign
- B. Goodell's sign
- C. Ballottement
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all three signs (Chadwick's sign, Goodell's sign, and Ballottement) are probable signs of pregnancy. Chadwick's sign refers to bluish discoloration of the cervix, Goodell's sign is softening of the cervix, and Ballottement is a palpable rebound of the fetus against the examiner's fingers. These signs are indicative of pregnancy and are commonly observed in pregnant individuals. Therefore, the provider should expect to see all these findings in a pregnant client. The other choices (A, B, and C) are incorrect because each of these signs individually is a probable sign of pregnancy, and the question asks for all the expected findings, not just one or two of them.
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A healthcare provider is assisting with the care for a client who has a prescription for magnesium sulfate. The provider should recognize that which of the following are contraindications for the use of this medication? (Select all that apply)
- A. Fetal distress
- B. Cervical dilation greater than 6 cm
- C. Vaginal bleeding
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Magnesium sulfate is contraindicated in cases of fetal distress, cervical dilation greater than 6 cm, and vaginal bleeding. Fetal distress can be worsened by magnesium sulfate, and it can lead to respiratory depression in the newborn. Cervical dilation greater than 6 cm indicates advanced labor, where the risk of uterine atony and postpartum hemorrhage is increased with magnesium sulfate use. Vaginal bleeding may be a sign of placental abruption or other complications, which can be exacerbated by magnesium sulfate. Therefore, all three options are contraindications for the use of magnesium sulfate in this scenario.
A client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?
- A. This is due to an increase in blood volume.
- B. This is due to pressure from the uterus on the diaphragm.
- C. This is due to the weight of the uterus on the vena cava.
- D. This is due to increased cardiac output.
Correct Answer: C
Rationale: The correct answer is C: This is due to the weight of the uterus on the vena cava. Maternal hypotension during pregnancy can occur when the growing uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop in blood pressure. This compression can lead to decreased blood flow to the brain and other vital organs, resulting in symptoms of hypotension. The other choices are incorrect because:
A: An increase in blood volume during pregnancy typically leads to an increase in blood pressure, not hypotension.
B: Pressure from the uterus on the diaphragm may cause discomfort or shortness of breath but is not the primary cause of maternal hypotension.
D: Increased cardiac output is a normal adaptation in pregnancy to meet the demands of the growing fetus and placenta, but it does not directly cause maternal hypotension.
A client who is at 24 weeks of gestation is scheduled for a 1-hour glucose tolerance test. Which of the following statements should the nurse include in her teaching?
- A. You will need to drink the glucose solution 1 hour prior to the test.
- B. Limit your carbohydrate intake for 24 hours prior to the test.
- C. A blood glucose of 130 to 140 mg/dL is considered a positive screening result.
- D. You will need to fast for 8 hours prior to the test.
Correct Answer: C
Rationale: The correct answer is C: A blood glucose of 130 to 140 mg/dL is considered a positive screening result. This statement is the correct teaching point because for a 1-hour glucose tolerance test during pregnancy, a blood glucose level of 130-140 mg/dL is considered elevated and may indicate gestational diabetes. The other choices are incorrect: A is wrong because the glucose solution is typically consumed one hour before the test, not prior to the test itself. B is incorrect as limiting carbohydrate intake is not necessary for this test. D is also incorrect because fasting for 8 hours is not required for a 1-hour glucose tolerance test.
An adolescent is being taught about levonorgestrel contraception by a school nurse. What information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. Do not take this medication if you are on an oral contraceptive.
- C. If you do not start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent pregnancy for 14 days after taking it.
Correct Answer: A
Rationale: Step 1: Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours after unprotected sex.
Step 2: Taking the medication within the specified time frame increases its effectiveness in preventing pregnancy.
Step 3: Thus, the nurse should emphasize to the adolescent the importance of taking the medication promptly after unprotected intercourse.
Step 4: This information is crucial for the adolescent to understand the time-sensitive nature of levonorgestrel contraception.
Summary:
- Choice B is incorrect because it provides contradictory information. Levonorgestrel can be taken even if the individual is on an oral contraceptive.
- Choice C is incorrect as starting a period is not a reliable indicator of pregnancy. A pregnancy test is recommended if there are concerns.
- Choice D is incorrect because levonorgestrel is a single-dose emergency contraception and does not provide protection for 14 days.
During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?
- A. Back rub
- B. Counter-pressure
- C. Playing music
- D. Foot massage
Correct Answer: B
Rationale: The correct answer, B: Counter-pressure, is the best nonpharmacological intervention for a client with a posterior fetal head position causing lower back pain. Counter-pressure applied to the sacrum can help alleviate discomfort by reducing pressure on the lower back and providing support during contractions. This technique can aid in rotating the baby's head to a more optimal position for delivery.
Choice A: Back rub, may offer some comfort but may not specifically address the issue of lower back pain caused by the fetal position. Choice C: Playing music, and Choice D: Foot massage, are unlikely to provide direct relief for the client's specific discomfort related to the baby's posterior position.