Nokea
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
- A. Prepare the woman for an abdominal ultrasound
- B. Place the patient on her left side to increase perfusion to the fetus
- C. Be prepared to discuss the action and side effects of progesterone
- D. Monitor the patient’s blood pressure closely
Correct Answer: C
Rationale: The correct answer is C because progesterone is a recommended treatment for cervical incompetency to prevent preterm birth. Progesterone helps support the uterine lining and decrease the risk of preterm labor. Therefore, discussing the action and side effects of progesterone with the patient is essential.
A: While an abdominal ultrasound may provide information about the cervix, it is not the immediate priority in this case.
B: Placing the patient on her left side is a common practice for improving blood flow, but it is not directly related to managing cervical incompetency.
D: Monitoring blood pressure is important in prenatal care, but it is not specifically related to the management of cervical incompetency in this context.
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The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick showing protein of 3+ indicates significant proteinuria, a sign of preeclampsia in pregnancy. Preeclampsia can lead to serious complications for both the mother and the baby, such as eclampsia and fetal growth restriction. The nurse should further assess the client's blood pressure, perform additional tests for preeclampsia, and closely monitor the client's condition.
Choice A: Hemoglobin and hematocrit levels are within normal range for pregnancy and do not require immediate intervention.
Choice B: Blood pressure of 130/80 is slightly elevated but not concerning at this gestational age. Close monitoring is recommended.
Choice C: Slight pedal swelling is common in pregnancy due to fluid retention and usually does not indicate a serious issue.
A nurse is monitoring a client with type 2 diabetes mellitus. Her blood work reveals a glycosylated hemoglobin (HbA1c) of 10%. The nurse knows this blood work indicates which of the following?
- A. A normal value indicating that the client is managing blood glucose control well
- B. A low value indicating that the client is not managing blood glucose control very well
- C. A high value indicating that the client is not managing blood glucose control very well
- D. The value does not offer information regarding client management of her disease
Correct Answer: C
Rationale: Rationale:
1. HbA1c reflects average blood glucose levels over the past 2-3 months.
2. A value of 10% indicates poor blood glucose control.
3. High HbA1c (above 6.5-7%) signifies uncontrolled diabetes.
4. Choice C is correct as it aligns with the interpretation of HbA1c.
Summary:
- Choice A is incorrect as 10% is not a normal HbA1c value.
- Choice B is incorrect as a low value would indicate good control.
- Choice D is incorrect as HbA1c is a key marker for diabetes management.
During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
- A. Orthopnea
- B. Pulmonary edema
- C. Anemia
- D. Decreased blood volume
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect suggests pulmonary edema. This is due to fluid accumulation in the lungs, leading to coughing. Pulmonary edema can occur due to increased blood volume and pressure on the heart during pregnancy, exacerbating the client's pre-existing heart condition. Orthopnea (choice A) is difficulty breathing while lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not directly linked to a nonproductive cough. Decreased blood volume (choice D) is unlikely in a pregnant client and would not explain the cough.
The nurse is providing discharge instructions to a 28-year-old client who received methotrexate for an ectopic pregnancy. Which should the discharge instructions include?
- A. Make sure to take folic acid
- B. Make an appointment to see her provider in 6 weeks
- C. Flush the toilet twice after she urinates for the next 24 hours
- D. Resume all activity in 48 hours
Correct Answer: C
Rationale: The correct answer is C. Methotrexate is a chemotherapy agent that can be harmful to others if not properly eliminated from the body. Instructing the client to flush the toilet twice after urination for the next 24 hours helps to reduce the risk of exposing others to the medication through urine. This precaution is important to prevent potential harm to others.
Choices A, B, and D are incorrect:
A: Taking folic acid is generally recommended to reduce side effects of methotrexate but is not directly related to the safety of others.
B: While follow-up appointments are important, the immediate safety concern of methotrexate elimination is more critical.
D: Resuming all activity in 48 hours may not be appropriate depending on the individual's response to methotrexate and their recovery process.