Nokea
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.
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A nurse is providing prenatal care to a pregnant client. At which time would the nurse expect to screen the client for group B streptococcus infection?
- A. 28 weeks' gestation
- B. 32 weeks' gestation
- C. 16 weeks' gestation
- D. 36 weeks' gestation
Correct Answer: D
Rationale: Screening for group B streptococcus (GBS) is done at 35-37 weeks (36 weeks is closest) to assess colonization status near delivery, guiding intrapartum antibiotic use to prevent neonatal infection. Earlier screening (16, 28, or 32 weeks) may not reflect status at birth, as GBS colonization can change.
After reviewing the information provided in the client's medical record, which of the following complications should the nurse identify that the client is at risk of developing?
- A. Preeclampsia; uric acid
- B. Gestational diabetes; glucose
- C. Eclampsia; magnesium
- D. Placenta previa; hemoglobin
Correct Answer: B
Rationale: Gestational diabetes risk is linked to glucose intolerance, detectable by serum glucose levels, causing complications like macrosomia. Preeclampsia involves hypertension, not uric acid alone; eclampsia isn't tied to magnesium levels; placenta previa relates to prior surgeries, not hemoglobin.
When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
- A. Ambivalence
- B. Emotional lability
- C. Introversion
- D. Acceptance
Correct Answer: B
Rationale: Emotional lability is typical in the first trimester from hormonal changes causing irritability or crying. Ambivalence is less common unless conflicted, introversion isn't pregnancy-specific, and acceptance grows over time.
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.