Nokea
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. This shot may be given after birth to protect future pregnancies.
- B. If my partner is Rh-negative, I will not receive the shot.
- C. I will receive the shot after delivery if my baby is Rh-negative.
- D. I should not receive any immunizations for 3 months after the shot.
Correct Answer: A
Rationale: Rho(D) immune globulin administered postpartum prevents maternal sensitization to Rh-positive fetal blood cells, reducing risks of hemolytic disease in subsequent pregnancies by suppressing maternal immune response.
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A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full-term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client's obstetrical history as which of the following?
- A. Gravida 3, Para 2.
- B. Gravida 3, Para 3.
- C. Gravida 4, Para 2.
- D. Gravida 4, Para 3.
Correct Answer: C
Rationale: Gravida 4 reflects the client's total pregnancies, including the current one and her abortion, while Para 2 accounts for her two full-term live births, accurately documenting her obstetrical history.
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 8 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase their intake during the first trimester of pregnancy?
- A. Vitamin E.
- B. Protein.
- C. Fiber.
- D. Calcium.
Correct Answer: B
Rationale: Protein requirements increase to support fetal growth, placental development, and maternal tissue expansion. Pregnant clients need approximately 1.1 g/kg/day, compared to 0.8 g/kg/day for non-pregnant individuals.
A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?
- A. You will receive a medication through an IV for this test.
- B. You should expect the test to take about 30 minutes.
- C. You should not eat or drink for 4 hours prior to the test.
- D. This test will help determine if your baby's lungs are mature.
Correct Answer: B
Rationale: Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity.
- B. Excessive high-pitched cry.
- C. Acrocyanosis.
- D. Respiratory rate of 50/min.
Correct Answer: B
Rationale: Excessive high-pitched crying results from central nervous system hyperirritability caused by withdrawal. Neonatal abstinence syndrome involves exaggerated responses to stimuli, reflecting the neonate's difficulty in self-regulation.
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 11/min.
- B. Deep tendon reflexes 2+.
- C. Urine output 30 mL/hr.
- D. Blood pressure 100/62 mm Hg.
Correct Answer: A
Rationale: A respiratory rate of 11/min is below the normal adult range of 12–20/min and indicates respiratory depression, a potential adverse effect of magnesium sulfate requiring immediate intervention.