Nokea
A nurse is reviewing the laboratory results for a client who is at 29 weeks.... the provider?
- A. WBC count
- B. 11,000/mm³ Hgb
- C. 11,2 g/Dl
- D. Hct 34% Platelets 140,000/mm³
Correct Answer: B
Rationale: The correct answer is B: 11,000/mm³ Hgb. At 29 weeks of gestation, hemoglobin (Hgb) levels are crucial to monitor for anemia in pregnant women. A Hgb level of 11,000/mm³ is within the normal range for a pregnant woman. Anemia during pregnancy can lead to adverse outcomes for both the mother and the baby, such as preterm birth and low birth weight.
Rationale for other choices:
A: WBC count - While monitoring white blood cell (WBC) counts is important for detecting infections, it is not the most relevant parameter to review in this scenario.
C: 11,2 g/Dl - This choice is incomplete and doesn't provide a specific parameter or context for interpretation.
D: Hct 34% Platelets 140,000/mm³ - Hematocrit (Hct) and platelet levels are important, but in this case, the Hgb level is more pertinent
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A client at 37 weeks' gestation reports swollen feet and hands. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/95 mmHg.
- B. Weight gain of 1 pound in a week.
- C. Mild nausea after eating.
- D. Fetal movements are regular.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure of 150/95 mmHg. This finding indicates gestational hypertension, which can progress to preeclampsia, a serious condition that requires immediate intervention to prevent complications for both the mother and baby. High blood pressure can lead to organ damage and placental insufficiency.
B: Weight gain of 1 pound in a week is within the normal range for late pregnancy and may not require immediate intervention.
C: Mild nausea after eating is a common pregnancy symptom and does not indicate an urgent issue.
D: Regular fetal movements are a positive sign of fetal well-being and do not require immediate intervention.
What question during a family assessment could the nurse ask to determine if the family has necessary resources?
- A. Do you enjoy spending time with your family?
- B. Do you have a group of friends, neighbors, or a church that helps you when you are ill?
- C. How often do you go to the store by yourself?
- D. Do your family members get along well?
Correct Answer: B
Rationale: The correct answer is B: "Do you have a group of friends, neighbors, or a church that helps you when you are ill?" This question assesses the family's support network and resources in times of need. It helps determine if the family has a social support system that can provide assistance during challenging situations. Options A, C, and D are incorrect as they do not directly address the availability of external resources for the family's well-being. Option A focuses on emotional aspects, C on independence, and D on family dynamics, which are not directly related to assessing resources.
The nurse is preparing a client for a biophysical profile (BPP). What does this test evaluate?
- A. Maternal blood flow to the placenta.
- B. Fetal genetic abnormalities.
- C. Fetal well-being, including movements and amniotic fluid.
- D. Cervical dilation and effacement.
Correct Answer: C
Rationale: The correct answer is C: Fetal well-being, including movements and amniotic fluid. A Biophysical Profile evaluates the fetus' health by assessing factors like fetal movements, muscle tone, breathing movements, amniotic fluid volume, and fetal heart rate patterns. This test provides valuable information about the fetus' well-being and helps in determining the need for interventions or further monitoring.
Explanation of why the other choices are incorrect:
A: Maternal blood flow to the placenta is not evaluated by a Biophysical Profile.
B: Fetal genetic abnormalities are not assessed through a BPP; it focuses on the fetus' current well-being.
D: Cervical dilation and effacement are related to labor progress and not part of a BPP, which focuses on fetal well-being.
A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that she has a daily heroin habit. The nurse discusses treatment options for the patient. Which patient statement requires follow-up?
- A. "My plan is to visit the outpatient clinic daily for treatment."
- B. "will see my health care provider at least every 2 weeks."
- C. "My baby will not have to go through withdrawal when I take methadone."
- D. "With oral methadone, my baby and I are at decreased risk of infection."
Correct Answer: B
Rationale: The correct answer is B because seeing the healthcare provider every 2 weeks may not be frequent enough for monitoring a pregnant patient with a heroin habit. Regular monitoring is crucial for the well-being of both the mother and the baby. Option A shows a proactive approach for daily treatment, Option C is incorrect as methadone does not eliminate the risk of withdrawal in newborns, and Option D is incorrect as methadone does not reduce the risk of infection. Regular and close monitoring is essential in such cases to ensure the safety and health of both the mother and the baby.
The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.