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A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.
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A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: The best time to schedule the ultrasound immediately is because in early pregnancy, it is crucial to confirm the gestational age, rule out ectopic pregnancy, and assess fetal viability. This allows for accurate dating, identification of potential complications, and timely interventions if needed. Waiting for 2, 4, or 6 weeks could delay necessary care and potentially compromise the well-being of the patient and the fetus. Early detection and management of any issues are essential in ensuring a healthy pregnancy outcome.
A woman and man have the following genotypes for an autosomal dominant disease: Aa and Aa. If asked, which of the following should the nurse say is the probability of their child having the disease?
- A. 25% probability.
- B. 50% probability.
- C. 75% probability.
- D. 100% probability.
Correct Answer: C
Rationale: The probability of their child having the disease is 75% because both parents are carriers (Aa). The possible genotypes for the child are AA, Aa, aA, and aa. Only the aa genotype would not result in the disease, giving a 75% chance of the child having the disease.
The nurse in the obstetrician’s office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor?
- A. African American, 15 years old, with newly diagnosed gestational diabetes.
- B. Asian American, 23 years old, with five-year-old twins who were born at term.
- C. Jewish, 25 years old, working as a certified public accountant.
- D. Mormon, 33 years old, who recently moved into a new apartment.
Correct Answer: A
Rationale: Young age and gestational diabetes are risk factors for preterm labor, making it important to educate this client.
The health care practitioner caring for a pregnant client diagnosed with gonorrhea writes the following order: ceftriaxone 250 mg IM × one dose. The medication is available in 1-gram vials. The nurse adds 8 mL of normal saline to the vial. How many mL of the medication should the nurse administer? Calculate to the nearest whole.
- A. 2 mL
- B. 3 mL
- C. 4 mL
- D. 5 mL
Correct Answer: A
Rationale: The nurse should administer 2 mL of the medication. The calculation is based on the concentration of the medication after dilution.
The nurse has admitted a client who is 30 weeks gestation with suspected intrauterine growth restriction. The physician has ordered a Doppler blood flow study. What does the nurse suspect if the results show an S/D ratio above the 95th percentile for the gestational age, a ratio above 3, or end-diastolic blood flow that is absent or reversed?
- A. Decreased blood pressure
- B. Placental insufficiency
- C. Increased amniotic fluid
- D. Decreased fetal movement
Correct Answer: B
Rationale: The correct answer is B: Placental insufficiency. An elevated S/D ratio (>95th percentile for gestational age or >3) and absent/reversed end-diastolic blood flow on Doppler study indicate impaired placental blood flow, leading to decreased oxygen and nutrient delivery to the fetus. This can result in intrauterine growth restriction (IUGR) and compromise fetal well-being. Decreased blood pressure (A) is not directly related to these Doppler findings. Increased amniotic fluid (C) is more commonly associated with conditions like fetal anomalies or maternal diabetes. Decreased fetal movement (D) may be a sign of fetal distress but is not specifically indicated by Doppler findings in IUGR.