Nokea
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
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A pregnant client asks about the purpose of an ultrasound at 20 weeks' gestation. What is the best response?
- A. To confirm pregnancy viability.
- B. To check for genetic abnormalities.
- C. To assess fetal anatomy and growth.
- D. To determine the sex of the baby.
Correct Answer: C
Rationale: The 20-week ultrasound is primarily for assessing fetal anatomy, growth, and development.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action?
- A. Verify signed informed consent.
- B. Administer prescribed analgesics.
- C. Encourage the client to empty their bladder.
- D. Position the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.
A pregnant client tells the clinic nurse she wants to know the sex of her baby as soon as it can be determined. What factor allows this at 12 weeks' gestation?
- A. The appearance of the fetal external genitalia
- B. The beginning of differentiation in the fetal groin
- C. The fetal testes are descended into the scrotal sac
- D. The internal differences in males and females become apparent
Correct Answer: A
Rationale: By 12 weeks, the external genitalia are sufficiently developed for visual determination of the baby's sex.
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.
The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?
- A. At the first prenatal visit.
- B. Between 35–37 weeks' gestation.
- C. During the second trimester.
- D. After 40 weeks' gestation.
Correct Answer: B
Rationale: GBS testing is typically performed between 35–37 weeks to identify and manage infection risks during delivery.