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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: The correct answer is A (Blood pressure of 155/95) because an elevated blood pressure indicates worsening pre-eclampsia. In pre-eclampsia, high blood pressure is a key indicator of worsening condition, potentially leading to eclampsia or seizures if left untreated. Choices B (Urinary output is greater than 30 mL/hr), C (Deep tendon reflexes +2), and D (Client complains of blurred vision) are not indicative of worsening pre-eclampsia. Increased urinary output, normal deep tendon reflexes, and blurred vision are common symptoms in pre-eclampsia, but they do not necessarily signify worsening of the condition.
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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: Rationale for correct answer (A): Changing cat litter exposes the woman to Toxoplasma gondii, a parasite associated with chorioamnionitis. It is a known risk factor as the infection can spread to the fetus.
Summary of incorrect choices:
B (Frequent vaginal examination during labor): This does not directly increase the risk of chorioamnionitis.
C (Gestational diabetes): While gestational diabetes can have other complications, it is not a direct risk factor for chorioamnionitis.
D (Preterm premature rupture of the membranes): While this can increase the risk of infection, it is not a specific risk factor for chorioamnionitis.
The nurse is caring for a client with severe hyperemesis gravidarum. She is 10 weeks gestation and has a 10% weight loss. The client is being admitted for fluid and electrolyte replacement. The nurse is aware it is important to check which deficiency that puts the client at risk for Wernicke’s encephalopathy?
- A. Folic acid
- B. Vitamin D
- C. Thiamine
- D. Glucose
Correct Answer: C
Rationale: The correct answer is C: Thiamine. In severe hyperemesis gravidarum, excessive vomiting can lead to thiamine deficiency, increasing the risk of Wernicke's encephalopathy, a neurological disorder. Thiamine is essential for the brain's energy metabolism. Without adequate thiamine, neurological symptoms such as confusion, memory issues, and ataxia can arise. Folic acid (choice A) is important for neural tube development but not directly related to Wernicke's encephalopathy. Vitamin D (choice B) deficiency can lead to various issues but is not associated with Wernicke's encephalopathy. Glucose (choice D) is a source of energy but does not directly influence thiamine deficiency and Wernicke's encephalopathy.
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 important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
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 assessing a client who has been diagnosed with gestational diabetes. Which should the nurse monitor closely because of her diagnosis?
- A. Edema
- B. Blood pressure, pulse, and respiration
- C. Urine for glucose and ketones
- D. Hemoglobin and hematocrit
Correct Answer: C
Rationale: The correct answer is C: Urine for glucose and ketones. In gestational diabetes, monitoring urine for glucose and ketones is crucial to assess blood sugar control and ketosis. Glucose in urine indicates hyperglycemia, and ketones indicate inadequate insulin and potential ketoacidosis. Monitoring edema (choice A) is not specific to gestational diabetes. Blood pressure, pulse, and respiration (choice B) are important but not specific to gestational diabetes. Monitoring hemoglobin and hematocrit (choice D) does not directly reflect blood sugar control in gestational diabetes.