Nokea
A nurse is assessing a pregnant patient at 34 weeks gestation who reports feeling itchy and has noticed jaundice. Which of the following conditions should the nurse suspect?
- A. Gestational diabetes
- B. Preeclampsia
- C. Cholestasis of pregnancy
- D. Hyperthyroidism
Correct Answer: C
Rationale: The correct answer is C: Cholestasis of pregnancy. This condition presents with itching, especially on the palms and soles, and jaundice. It is more common in the third trimester. Cholestasis of pregnancy is a liver condition that can lead to complications for both the mother and the baby if not managed promptly. Gestational diabetes (Choice A) presents with high blood sugar levels. Preeclampsia (Choice B) is characterized by high blood pressure and protein in the urine. Hyperthyroidism (Choice D) involves an overactive thyroid gland, which can present with symptoms such as weight loss and palpitations.
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A 37-week gravid client states that she noticed a 'white liquid' leaking from her breasts during a recent shower.
- A. Advise the woman that she may have a galactocele.
- B. Encourage the woman to pump her breasts to stimulate an adequate milk supply.
- C. Assess the liquid because a breast discharge is diagnostic of a mammary infection.
- D. Reassure the mother that this is normal in the third trimester.
Correct Answer: D
Rationale: In the third trimester, colostrum production can cause a white liquid to leak from the breasts. This is a normal physiological response as the body prepares for breastfeeding.
A 36-week gestation gravid lies flat on her back.
- A. Hypertension.
- B. Dizziness.
- C. Rales.
- D. Chloasma.
Correct Answer: B
Rationale: Lying flat on the back can compress the inferior vena cava, leading to reduced blood flow and dizziness. Chloasma, rales, and hypertension are unrelated to this position.
A nurse is assisting a laboring person with an epidural. What is the most important nursing intervention prior to the procedure?
- A. ensure proper positioning
- B. ensure informed consent
- C. monitor contractions
- D. assist with controlled breathing
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent. This is crucial before any medical procedure, including epidural administration. It ensures the laboring person understands the risks, benefits, and alternatives of the epidural. Proper positioning (choice A) is important during the procedure but not the most critical pre-procedure intervention. Monitoring contractions (choice C) and assisting with breathing (choice D) are important aspects of labor support but not directly related to obtaining informed consent for the epidural.
Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following?
- A. Avoid eating greasy foods.
- B. Drink orange juice before rising.
- C. Consume 1 teaspoon of nutmeg each morning.
- D. Eat 3 large meals plus a bedtime snack.
Correct Answer: A
Rationale: Greasy foods can exacerbate nausea and vomiting. Small, frequent meals are recommended, and saltine crackers before rising can help alleviate symptoms. Orange juice and nutmeg are not recommended.
A nurse is educating a pregnant patient who is at 30 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is safe and beneficial for pregnant women at 30 weeks gestation. Moderate exercise helps maintain health, improves circulation, reduces stress, and prepares the body for labor. Strenuous exercise (A) can be risky and may lead to complications. Avoiding all physical activity (C) can result in deconditioning and potential complications. High-impact exercises (D) can be too intense and pose a risk of injury during pregnancy. Prioritizing moderate exercise aligns with current guidelines for safe physical activity during pregnancy.