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 because epigastric pain in a pregnant client at 34 weeks of gestation could indicate a serious condition such as preeclampsia. Preeclampsia is a potentially life-threatening condition characterized by high blood pressure and organ damage. It requires immediate assessment and intervention to prevent complications for both the mother and the baby. The other clients have less urgent issues that can be managed with ongoing monitoring and interventions. A: Gestational diabetes with a slightly elevated blood glucose level can be managed with adjustments to diet and medication. C: Mildly low hemoglobin levels can be addressed with iron supplementation and monitoring. D: Urinary frequency and dysuria in a client at 39 weeks of gestation are common symptoms of late-stage pregnancy and do not indicate a critical issue.
You may also like to solve these questions
A nurse is reviewing the provider's prescription in the adolescent's medical chart
Exhibit 1
History and Physical, Adolescent is sexually active with two current partners.
IUD in place, Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Prompt reporting is crucial to prevent complications. Shortness of breath (A) and swelling of feet and ankles (B) are common in pregnancy but not necessarily indicative of a serious complication. Braxton Hicks contractions (D) are normal and not usually a cause for concern.
A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I will position my baby at a 45-degree angle in the car seat.
- B. I can place my baby in the front seat with the airbag turned off.
- C. I can turn my baby's car seat around when she weighs 15 pounds.
- D. I will place my baby in a forward-facing car seat in my back seat.
Correct Answer: A
Rationale: Correct Answer: A. "I will position my baby at a 45-degree angle in the car seat."
Rationale: Placing the newborn at a 45-degree angle in the car seat supports the baby's airway and prevents slumping, ensuring proper breathing and safety. This position helps reduce the risk of suffocation and allows the baby's head to be supported. It is recommended by pediatric experts as the safest way for a newborn to travel in a car seat.
Summary of other choices:
B: Placing a baby in the front seat with the airbag turned off is not safe, as the back seat is the safest place for children under 13 years old.
C: Turning the baby's car seat around at 15 pounds is incorrect as rear-facing is recommended until at least 2 years of age.
D: Using a forward-facing car seat for a newborn is unsafe, as infants should be in a rear-facing seat until they outgrow the height or weight limit.
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. Following an amniocentesis, leakage of fluid from the vagina can indicate a potential complication such as amniotic fluid leakage, which can lead to preterm labor or infection. This finding should be reported to the provider promptly for further evaluation and management. Increased fetal movement (choice A) is a normal occurrence and not typically indicative of a complication. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common side effects post-amniocentesis and usually resolve without intervention.
A nurse is caring for a postpartum client in an outpatient setting
Exhibit1:
History and Physical
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation.
Newborn 4,508 g (9 lb 15 oz), APGARs: 8 at 1 min, 9 at 5 min
group B streptococcus 8-hemolytic: positive (negative)
Received 2 doses of Intravenous penicillin G while in labor”
complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
- A. Endometritis.
- B. Mastitis.
- C. Postpartum hemorrhage.
- D. Group B streptococcus positive status.
- E. Spontaneous vaginal delivery.
- F. Median episiotomy.
Correct Answer: A
Rationale: The correct answer is A: Endometritis. The client is at highest risk for developing endometritis evidenced by the client's median episiotomy. Endometritis is an infection of the lining of the uterus and is commonly associated with invasive procedures like episiotomy. The incision from a median episiotomy provides a pathway for bacteria to enter the uterus, increasing the risk of infection. The other choices are incorrect because mastitis is related to breastfeeding, postpartum hemorrhage is excessive bleeding after childbirth, group B streptococcus positive status is a risk for neonatal infection, and spontaneous vaginal delivery is a mode of delivery not directly related to endometritis.