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A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: A fetal heart rate (FHR) of 152/min is within the normal range of 110 to 160 beats per minute for a fetus at 18 weeks of gestation.
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A nurse is caring for a client who is in labor and receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Contractions every 5 min that last 30 seconds
- B. Montevideo units consistently 300 mm Hg
- C. Urine output of 20 mL/hr
- D. FHR pattern with absent variability
Correct Answer: A
Rationale: Contractions every 5 minutes lasting 30 seconds are inadequate for labor progression, indicating the need to increase oxytocin infusion to strengthen contractions.
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy.
- C. The hepatitis B immunization should not be obtained until after you finish breastfeeding.
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during any trimester of pregnancy to protect both the mother and the baby.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, resulting in a foul-smelling, greenish-yellow vaginal discharge. This characteristic discharge is due to the infection and inflammation of the vaginal mucosa. Option A (Thick, white vaginal discharge) is more indicative of a yeast infection, while option B (Urinary frequency) is not specific to trichomoniasis. Option C (Vulva lesions) is not a common symptom of trichomoniasis. Overall, the malodorous discharge is the key finding in diagnosing trichomoniasis at 20 weeks of gestation.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I will eat foods that taste good instead of balancing my meals."
- B. "I will avoid having a snack before I go to bed each night."
- C. "I will have a cup of hot tea with each meal."
- D. "I will eliminate products that contain dairy from my diet."
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is because hyperemesis gravidarum is a condition characterized by severe nausea and vomiting during pregnancy. Dairy products can be harder to digest and may exacerbate nausea. By eliminating dairy, the client can reduce the likelihood of triggering nausea and vomiting.
A: "I will eat foods that taste good instead of balancing my meals." - This statement does not address the dietary changes needed for hyperemesis gravidarum.
B: "I will avoid having a snack before I go to bed each night." - While avoiding snacks before bedtime can be a good practice for some, it does not specifically address the dietary needs of hyperemesis gravidarum.
C: "I will have a cup of hot tea with each meal." - Hot tea may not necessarily help with managing hyperemesis gravidarum symptoms and does not address the need for dietary modifications.