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A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is because an increase in energy is often seen in pregnant women shortly before labor begins, known as the "nesting instinct." This burst of energy can indicate that the body is preparing for labor.
A: Decreased vaginal discharge is not a sign that precedes labor. In fact, an increase in vaginal discharge is more common as labor approaches.
C: Urinary retention is not a sign of labor onset. In late pregnancy, pressure on the bladder may cause frequent urination, but retention is not typical.
D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor onset. Weight gain can fluctuate throughout pregnancy and is not a reliable indicator of impending labor.
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The nurse is assessing a client with a suspected diagnosis of abruptio placentae. Which finding is most indicative of this condition?
- A. Soft abdomen.
- B. Uterine tenderness and rigidity.
- C. Bright red, painless vaginal bleeding.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness and rigidity. This finding is most indicative of abruptio placentae, which is the premature separation of the placenta from the uterine wall. Uterine tenderness and rigidity are classic signs due to the internal bleeding and blood accumulating between the placenta and uterine wall. This results in a tense and tender uterus.
A: Soft abdomen is incorrect as abruptio placentae typically presents with a firm, board-like abdomen due to uterine rigidity.
C: Bright red, painless vaginal bleeding is incorrect as abruptio placentae typically presents with dark red, painful vaginal bleeding.
D: Decreased fetal movements are incorrect as fetal distress can occur with abruptio placentae, but uterine tenderness and rigidity are more specific indicators of this condition.
The nurse is assessing a client with suspected chorioamnionitis. What is the priority nursing assessment?
- A. Assess for foul-smelling vaginal discharge.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check maternal glucose levels.
Correct Answer: C
Rationale: The correct answer is C: Evaluate fetal heart rate. In chorioamnionitis, fetal distress can occur due to infection and inflammation of the fetal membranes. Monitoring fetal heart rate is crucial to assess the well-being of the baby. Assessing for foul-smelling discharge (A) is important but not the priority. Monitoring maternal blood pressure (B) and checking glucose levels (D) are relevant assessments but do not address the immediate risk of fetal distress in chorioamnionitis.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Document the findings and continue to monitor the client.
- B. Notify the client's provider.
- C. Increase the frequency of fundal massage.
- D. Encourage the client to empty her bladder.
Correct Answer: A
Rationale: The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition.
Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline.
Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone.
Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicill in
- B. Azithro mycin
- C. Ceftriax one
- D. Acyclov ir
Correct Answer: A
Rationale: The correct answer is A: Ampicillin. Group B Streptococcus (GBS) infection during labor is typically treated with intravenous antibiotics like ampicillin to prevent transmission to the newborn. Ampicillin is the first-line treatment for GBS during labor due to its effectiveness in eradicating the bacteria and reducing the risk of neonatal infection. Azithromycin (B) is not typically used for GBS infection during labor. Ceftriaxone (C) is not the preferred antibiotic for GBS during labor. Acyclovir (D) is used to treat viral infections, not bacterial infections like GBS.
A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.