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: Epigastric pain in a pregnant client can be a sign of preeclampsia or HELLP syndrome, both of which are serious conditions that require immediate medical attention.
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A nurse is performing an initial assessment of a newborn. Which of the following actions should the nurse take to prevent any heat loss through conduction?
- A. Cover the scale with a warmed blanket before weighing the baby
- B. Evaluate respirations by observing the newborn's uncovered chest for 1 min.
- C. Place the newborn's crib away from of an air vent to perform the assessment.
- D. Perform the assessment immediately after birth before removing amniotic fluid.
Correct Answer: A
Rationale: Covering the scale with a warmed blanket prevents heat loss through conduction, which occurs when the newborn comes into contact with a cold surface.
Which of the following is a potential complication of maternal obesity during pregnancy?
- A. Gestational diabetes
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: D
Rationale: Maternal obesity can lead to gestational diabetes, preterm labor, and fetal macrosomia.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: Oxytocin is administered postpartum to manage uterine atony (flaccid uterus) and control excessive bleeding, which are common indications for its use.
Which of the following is a potential complication of maternal hyperemesis gravidarum?
- A. Preterm labor
- B. Fetal growth restriction
- C. Maternal dehydration
- D. All of the above
Correct Answer: D
Rationale: Hyperemesis gravidarum can lead to preterm labor, fetal growth restriction, and maternal dehydration.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. In peripartum cardiomyopathy, monitoring blood pressure is crucial to detect any signs of worsening cardiac function or complications. Regular assessment can help identify hypertension or hypotension, which are common in this condition. Misoprostol (A) is not indicated for peripartum cardiomyopathy. Restricting oral fluid intake (C) can be harmful as adequate hydration is important postpartum. Administering an IV bolus of lactated Ringer's (D) may not be necessary unless specifically ordered by the healthcare provider based on the client's condition.