Nokea
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?
- A. The client has a fundal height of 38 cm
- B. The client has a fasting blood glucose of 90 mg/dL
- C. The client reports 12 fetal movements in 1 hr
- D. The client has nonpitting pedal edema
Correct Answer: A
Rationale: A fundal height of 38 cm at 32 weeks suggests macrosomia, a gestational diabetes complication, requiring reporting, unlike normal glucose, fetal movements, or edema.
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A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply pressure to the top of your uterus during contractions.
- B. Your partner will apply steady pressure with a tennis ball to your lower back.
- C. Your partner will apply continuous, firm pressure between your thumb and index finger.
- D. Your partner will apply upward pressure on your lower abdomen between contractions.
Correct Answer: B
Rationale: Counterpressure on the lower back with a tennis ball relieves labor pain, unlike uterine pressure (harmful), hand pressure (ineffective), or abdominal pressure (unrelated to pain relief).
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will return to the clinic in 8 weeks for my next injection
- B. I will get two shots each time I receive this medication
- C. I should increase my calcium intake while taking this medication
- D. I should discontinue this medication if I experience spotting
Correct Answer: C
Rationale: Increased calcium intake mitigates bone density loss from medroxyprogesterone, unlike incorrect 8-week injections (12 weeks), multiple shots, or stopping for spotting (normal).
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. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Bathe the newborn before initiating skin-to-skin contact.
- D. Administer a pneumococcal immunization to the newborn within 4 hr following birth.
Correct Answer: C
Rationale: Bathing the newborn removes maternal fluids, reducing HIV transmission risk, unlike stopping antiretrovirals (continued), scalp electrodes (increase risk), or pneumococcal vaccine (not routine).
A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
- A. A newborn who has a short frenulum and is having difficulty breastfeeding
- B. A newborn who is 24 hr old and has not had a meconium stool
- C. A newborn who is 10 hr old and has blood-tinged discharge in her diaper
- D. A newborn who is 10 hr old and has new onset tachypnea
Correct Answer: D
Rationale: New onset tachypnea signals potential respiratory distress, requiring urgent assessment, unlike breastfeeding issues, delayed stool, or normal blood-tinged discharge.
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
- A. Decrease in frequency of contractions
- B. BP 150/100 mm Hg
- C. Absent deep tendon reflexes
- D. Urinary output 35 mL/hr
Correct Answer: C
Rationale: Absent deep tendon reflexes indicate magnesium toxicity, a serious complication requiring immediate reporting to prevent further harm, unlike reduced contractions (desired effect), elevated BP (monitor but less urgent), or low-normal urine output.