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A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
- A. Blood pressure of 155/95
- B. Urinary output is greater than 30 mL/hr
- C. Deep tendon reflexes +2
- D. Client complains of blurred vision
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A blood pressure of 155/95 indicates hypertension, a key feature of worsening pre-eclampsia. Hypertension in pre-eclampsia can lead to serious complications like eclampsia. High blood pressure can put the client at risk for seizures, stroke, and organ damage.
Incorrect choices:
B: Urinary output > 30 mL/hr is a positive sign, indicating adequate renal function, which is desirable in pre-eclampsia.
C: Deep tendon reflexes +2 are within normal limits and do not necessarily indicate worsening pre-eclampsia.
D: Blurred vision is a common symptom of pre-eclampsia but not a definitive sign of worsening condition.
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The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications.
Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.
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.
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: Flush the toilet twice after she urinates for the next 24 hours. Methotrexate is excreted in urine and can be harmful if it comes into contact with others. Flushing the toilet twice helps to minimize the risk of exposure to others. Choice A is incorrect because although folic acid supplementation may be necessary with methotrexate, it is not the priority in this scenario. Choice B is incorrect as the client should be advised to seek immediate medical attention if any concerning symptoms occur, rather than waiting for 6 weeks. Choice D is incorrect as the client needs to avoid certain activities for a period of time after receiving methotrexate to prevent complications.
Which factor places the client at the highest risk of pre-eclampsia?
- A. White race
- B. Multiparity
- C. Obesity
- D. Infertility
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a major risk factor for pre-eclampsia due to the increased strain on the cardiovascular system, leading to hypertension and other complications during pregnancy. Multiparity (B) is associated with a lower risk of pre-eclampsia, as previous pregnancies can provide some level of protection. Infertility (D) is not a known risk factor for pre-eclampsia. White race (A) is not a definitive risk factor for pre-eclampsia, as it can affect individuals of all races.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: The correct answer is A: Changing cat litter. Chorioamnionitis is an infection of the amniotic fluid and membranes. Changing cat litter exposes the woman to toxoplasmosis, a risk factor for chorioamnionitis. Choices B, C, and D are incorrect. Vaginal exams during labor can introduce bacteria but are not a direct risk factor. Gestational diabetes is unrelated, and preterm premature rupture of membranes can increase infection risk but is not a direct cause like exposure to toxoplasmosis.