Nokea
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?
- A. Spotting
- B. Nausea
- C. Polyhydramnios
- D. Uterine tenderness
Correct Answer: A
Rationale: Spotting is a common symptom of placenta previa due to the abnormal placement of the placenta near or over the cervix. Nausea, polyhydramnios, and uterine tenderness are not typically associated with this condition.
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A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client’s condition to the local health department.
Correct Answer: D
Rationale: Reporting the client’s HIV status to the local health department is a legal requirement to ensure proper public health tracking and intervention.
Which of the following is a potential complication of postpartum depression?
- A. Poor bonding with the newborn
- B. Insufficient milk production
- C. Increased risk of postpartum hemorrhage
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A: Poor bonding with the newborn. Postpartum depression can hinder the mother's ability to emotionally connect with her baby, leading to poor bonding. This can impact the baby's development and the mother's ability to provide adequate care. Choice B is incorrect as milk production is more related to physical factors rather than mental health. Choice C is incorrect as postpartum hemorrhage is a separate medical issue. Choice D is incorrect as it includes all options, which is not accurate in this case.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This is a concerning symptom that could indicate a serious condition like preeclampsia, which can be life-threatening for both the mother and the baby. Headaches that are severe and persistent, especially when accompanied by other symptoms like visual disturbances and high blood pressure, should be reported promptly.
Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is also common in pregnancy and usually not a cause for concern unless it is sudden, severe, or accompanied by other symptoms. Braxton Hicks contractions (D) are normal practice contractions that do not indicate labor unless they become regular and intense.
The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe? Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for ------------------------------ and --------------------------
- A. fuconazole
- B. doxycycline
- C. Ceftriaxone
- D. acyclovir
- E. imiquimod
Correct Answer: B,C
Rationale:
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is crucial in preventing compression and desiccation of the umbilical cord, which could lead to decreased blood flow and oxygen delivery to the fetus. By covering the cord, the nurse can protect it from further damage while waiting for emergency intervention. Performing a vaginal examination (choice A) could worsen the situation by causing more pressure on the cord. Administering oxygen (choice C) may be important later but is not the immediate priority. Initiating IV fluids (choice D) is not the most urgent action in this scenario.