Nokea
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating
- A. Hemodilution of pregnancy
- B. A multiple gestation pregnancy
- C. Greater-than-expected weight gain
- D. Iron-deficiency anemia
Correct Answer: A
Rationale: Hemodilution of pregnancy occurs as plasma volume increases more than red blood cell mass, lowering hemoglobin to 10.5-14 g/dL in the second trimester, which includes 11 g/dL. Multiple gestation may raise hemoglobin, weight gain doesn't affect it, and iron-deficiency anemia typically shows lower hemoglobin with symptoms like fatigue.
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A nurse is preparing to administer chlordiazepoxide 50 mg PO every 8 hours to a client. The amount available is chlordiazepoxide 25 mg per capsule. How many capsules should the nurse administer per dose?
- A. 2 capsules
- B. 1 capsule
- C. 3 capsules
- D. 4 capsules
Correct Answer: A
Rationale: Dose (50 mg) / concentration (25 mg/capsule) = 2 capsules per dose. Other options miscalculate the number needed to achieve 50 mg.
A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?
- A. Wear spandex-type full-length pants
- B. Try elevating your legs when you sit
- C. Limit your intake of fluids
- D. Eliminate salt from your diet
Correct Answer: B
Rationale: Elevating legs reduces swelling by aiding venous return, a safe intervention for late-pregnancy edema. Tight pants worsen swelling, limiting fluids risks dehydration, and eliminating salt disrupts electrolytes.
A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating:
- A. Hemoconcentration by hypertension
- B. A multiple gestation pregnancy
- C. Greater-than-expected weight gain
- D. Iron-deficiency anemia
Correct Answer: D
Rationale: A hemoglobin of 11 g/dL is low for the second trimester (10.5-14 g/dL), suggesting iron-deficiency anemia, especially with symptoms like fatigue. Hemoconcentration raises hemoglobin, multiple gestation lowers it slightly, and weight gain is unrelated.
During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as:
- A. Ortolani's sign
- B. Chadwick's sign
- C. Goodell's sign
- D. Hegar's sign
Correct Answer: D
Rationale: Hegar's sign is softening of the lower uterine segment, felt early in pregnancy. Ortolani's tests infant hips, Chadwick's is cervical discoloration, and Goodell's is cervical softening, not uterine.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
- A. I'm sorry you lost your baby.
- B. Why are you crying?
- C. Will a pill help your pain?
- D. A baby still wasn't formed in your womb.
Correct Answer: A
Rationale: Saying 'I'm sorry you lost your baby' acknowledges the client's emotional loss empathetically. Asking why she's crying invalidates her feelings, focusing on physical pain ignores emotional needs, and claiming the baby wasn't formed is inaccurate and insensitive, as miscarriage involves loss at any stage.