Nokea
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: The correct answer is B. The client at 34 weeks with epigastric pain is the priority as it could indicate preeclampsia, a serious condition requiring immediate attention to prevent harm to both the mother and the baby. Epigastric pain can be a sign of liver involvement in preeclampsia. Gestational diabetes (choice A) with slightly elevated blood glucose levels can be managed and monitored. Low hemoglobin levels at 28 weeks (choice C) may require treatment but are not as urgent as potential preeclampsia. Urinary symptoms at 39 weeks (choice D) could be indicative of a urinary tract infection, which is important but not as urgent as suspected preeclampsia.
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A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. This finding could indicate an amniotic fluid leak, which is a potential complication following an amniocentesis. Amniotic fluid leakage can lead to infection and preterm labor. Increased fetal movement (choice A) is a normal sign of fetal well-being. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common after an amniocentesis and are not typically concerning unless severe or persistent.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
Which of the following conditions is the client most likely developing?
- A. Pelvic inflammatory.
- B. Ectopic pregnancy.
- C. Pyclonephritis.
- D. C-reactive protein.
- E. Beta hCG.
- F. Urinalysis.
Correct Answer: A
Rationale: [1, 0, 0, 0, 0, 0]
The correct answer is A: Pelvic inflammatory. Pelvic inflammatory disease is an infection of the female reproductive organs, often caused by sexually transmitted infections. It presents with symptoms like pelvic pain, abnormal vaginal discharge, and fever. Ectopic pregnancy (B) is the implantation of a fertilized egg outside the uterus and presents with abdominal pain and vaginal bleeding. Pyelonephritis (C) is a kidney infection, typically causing fever and flank pain. C-reactive protein (D) is a marker for inflammation and infection, not a specific condition. Beta hCG (E) is a hormone produced in pregnancy. Urinalysis (F) is a test to analyze urine composition, not a condition.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The correct answer is C because continuing to take insulin even when experiencing nausea and vomiting is crucial for managing blood glucose levels in pregestational type 1 diabetes during pregnancy. Nausea and vomiting can lead to decreased food intake, which may result in hypoglycemia if insulin doses are not adjusted accordingly. It is important for the client to maintain stable blood glucose levels for optimal fetal health.
Summary of Incorrect Choices:
A: Increasing insulin doses during the first trimester may not be necessary and should be done under the guidance of a healthcare provider.
B: Exercising with blood glucose levels of 250 or greater is not safe and can lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes and should be avoided in diabetes management.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps create a soothing and comforting environment for the baby. This position mimics the closeness and security of being held, promoting bonding and emotional connection between the guardian and the newborn. It also aids in digestion and reduces the risk of choking. Placing the newborn in the crib in a prone position (B) is unsafe as it increases the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may introduce unnecessary calories and disrupt feeding patterns. Preparing a bottle with rice cereal (D) can pose a choking hazard and is not recommended for newborns.