Nokea
A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.
- A. Nausea
- B. Abdominal enlargement
- C. Positive pregnancy test
- D. Braxton Hicks contractions
- E. Amenorrhea
Correct Answer: A,B,C,E
Rationale: Presumptive signs, subjective or non-definitive, include nausea (hormonal), abdominal enlargement (uterine growth), positive pregnancy test (hCG detection), and amenorrhea (missed periods). Braxton Hicks are probable signs, felt later.
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A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
- A. Difficulty in arousing
- B. Deep tendon reflexes 2+
- C. Urinary output of 30 mL per hour
- D. Respiratory rate of 10 breaths/minute
Correct Answer: B
Rationale: Deep tendon reflexes at 2+ indicate a therapeutic magnesium level, preventing seizures without toxicity. Difficulty arousing, low urinary output (below 40 mL/hr), or respiratory rate of 10 suggest toxicity, requiring intervention.
A nurse is preparing to administer penicillin G benzathine 1.2 million units IM now. The amount available is penicillin G benzathine 600,000 units/mL. How many mL should the nurse administer?
- A. 2 mL
- B. 1 mL
- C. 3 mL
- D. 4 mL
Correct Answer: A
Rationale: Formula: volume = dose / concentration. 1,200,000 units / 600,000 units/mL = 2 mL. Other options result from incorrect division or rounding errors.
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating
- A. Hemodilution of pregnancy
- B. A multiple gestation pregnancy
- C. Greater-than-expected weight gain
- D. Iron-deficiency anemia
Correct Answer: A
Rationale: Hemodilution of pregnancy occurs as plasma volume increases more than red blood cell mass, lowering hemoglobin to 10.5-14 g/dL in the second trimester, which includes 11 g/dL. Multiple gestation may raise hemoglobin, weight gain doesn't affect it, and iron-deficiency anemia typically shows lower hemoglobin with symptoms like fatigue.
When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
- A. Ambivalence
- B. Emotional lability
- C. Introversion
- D. Acceptance
Correct Answer: B
Rationale: Emotional lability is typical in the first trimester from hormonal changes causing irritability or crying. Ambivalence is less common unless conflicted, introversion isn't pregnancy-specific, and acceptance grows over time.
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year-old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:
- A. 3-2-1-0-3
- B. 4-1-1-1-3
- C. 4-2-1-3-1
- D. 3-1-2-2-3
Correct Answer: B
Rationale: GTPAL: Gravida (4 pregnancies: twins, son, abortion, current), Term (1 at 39 weeks), Preterm (1 at 34 weeks), Abortions (1 at 6 weeks), Living (3 children). Thus, 4-1-1-1-3 is correct. Other options miscalculate pregnancies, preterm births, or living children.