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A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to work harder to filter and remove excess sugar from the blood. This results in increased urination (polyuria) as the body tries to eliminate the excess glucose through urine. Double vision (A) is more indicative of neurological issues, sweating (C) can be due to various reasons such as anxiety or hormonal changes, and dizziness (D) may be related to blood pressure changes or inner ear problems. Therefore, increased urination is the most specific clinical finding associated with hyperglycemia in gestational diabetes mellitus.
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A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
- A. Ask the client to lie on her back in with her knees flexed
- B. Position one hand around the top of the client9s when fundus in one hand just above the client's symphysis pubis
- C. Rotate the upper hand to massage that clients uterus while using slight downward pressure to compress the fundus
- D. observe the client's perineum for the passage of clots and the amount of bleeding
Correct Answer: A,B,C,D
Rationale: Correct order of actions for fundal massage:
A: Ask the client to lie on her back with knees flexed - This position allows easy access to the uterus.
B: Position one hand around the top of the client's fundus and one hand just above the symphysis pubis - Proper positioning ensures effective massage.
C: Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus - This helps to stimulate contraction and control bleeding.
D: Observe the client's perineum for the passage of clots and the amount of bleeding - Monitoring for complications is essential.
Summary:
E: Not applicable - No action specified.
F: Not applicable - No action specified.
G: Not applicable - No action specified.
Incorrect choices:
The other choices are incorrect as they do not follow the logical sequence required for performing a fundal massage effectively and safely.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin to skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin to skin contact. This action is crucial to reduce the risk of HIV transmission from the mother to the newborn. By bathing the newborn before skin-to-skin contact, the nurse can remove any potential HIV-infected fluids from the baby's skin, reducing the risk of transmission. This step helps to protect the newborn while still allowing for important bonding through skin-to-skin contact after bathing.
Choice A is incorrect as the use of a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to newborn. Choice C is incorrect as stopping antiretroviral medication can significantly increase the risk of HIV transmission to the newborn. Choice D is incorrect as administering pneumococcal immunization is important but not within 4 hours following birth in the context of preventing HIV transmission.
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make?
- A. Avoid Eating snacks before bedtime
- B. Eat high-fat snack before getting out of bed
- C. Drink additional liquids with each meal
- D. Consume food served at cool temperatures
Correct Answer: D
Rationale: The correct answer is D: Consume food served at cool temperatures. This recommendation is based on the fact that pregnant women experiencing nausea and vomiting (commonly known as morning sickness) may find relief by consuming cold or cool foods, as they are less likely to trigger nausea compared to hot or warm foods. Cold foods also tend to have less of a strong smell, which can help reduce nausea. Avoiding snacks before bedtime (choice A) may not necessarily alleviate nausea in the morning. Eating high-fat snacks before getting out of bed (choice B) may worsen nausea. Drinking additional liquids with each meal (choice C) may not address the underlying cause of nausea and could potentially make it worse.
A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/ mm
- C. Creatine 0.8 mg/ dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/ mm. In pre-eclampsia, a low platelet count indicates thrombocytopenia, a serious complication that can lead to bleeding. This finding should be reported promptly to the provider for further evaluation and management. A: Hemoglobin level is within normal range and not a priority in pre-eclampsia. C: Creatinine level is normal and not directly related to the complications of pre-eclampsia. D: Urine protein concentration is elevated, which is expected in pre-eclampsia and should be monitored, but not as urgent as low platelet count.
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
- A. Initiate an infusion of IV fluids for the client
- B. Perform vaginal examination by applying upward pressure on the presenting part
- C. Administer oxygen via non rebreather mask at 8L/ min. D. Cover the umbilical cord with sterile saline saturated towel.
- D. Cover the umbilical cord with sterile saline saturated towel.
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This is the correct next step because it helps prevent compression of the cord, which could lead to fetal compromise. By covering the cord with a sterile saline towel, the nurse can protect it from drying out and maintain a moist environment. This step is crucial in preventing further harm to the fetus.
A: Initiate an infusion of IV fluids for the client - This is not the priority at this moment. The focus should be on managing the umbilical cord prolapse and fetal distress.
B: Perform vaginal examination by applying upward pressure on the presenting part - This action could potentially worsen the situation by further compressing the cord. It is not recommended in this scenario.
C: Administer oxygen via non-rebreather mask at 8L/min - While oxygenation is important for the client and fetus, managing the umbilical cord prolapse takes precedence in this situation.
In summary, covering