Nokea
A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply.
- A. Cloudy malodorous fluid
- B. Abdominal tenderness
- C. Fetal bradycardia
- D. Elevated maternal pulse rate
- E. Decreased C-reactive protein levels
Correct Answer: A,B,C,D
Rationale: Infection after membrane rupture shows as cloudy, foul fluid (bacterial contamination), abdominal tenderness (inflammation), fetal bradycardia (distress), and elevated pulse (systemic response). Decreased C-reactive protein doesn't indicate infection; it rises with inflammation.
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Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?
- A. Ferrous sulfate
- B. Potassium chloride
- C. Calcium carbonate
- D. Calcium gluconate
Correct Answer: D
Rationale: Calcium gluconate reverses magnesium toxicity (e.g., respiratory depression), a risk with magnesium sulfate used for preeclampsia. Ferrous sulfate treats anemia, potassium chloride corrects hypokalemia, and calcium carbonate is an antacid, none addressing toxicity.
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.
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?
- A. Marijuana
- B. Cocaine
- C. Nicotine
- D. Caffeine
Correct Answer: B
Rationale: Cocaine causes tachycardia, hypertension, and vasoconstriction, risking placental abruption and fetal distress. Marijuana causes relaxation, nicotine raises heart rate but vasodilates, and caffeine mildly stimulates but doesn't constrict vessels.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?
- A. Vitamin E requirements decrease during pregnancy due to the increase in body fat.
- B. Prenatal vitamins will meet your need for increased folic acid during pregnancy.
- C. You will need to double your intake of protein during pregnancy.
- D. You will need to increase your intake of calcium during pregnancy.
Correct Answer: B
Rationale: Prenatal vitamins provide 600 mcg/day folic acid, meeting pregnancy needs to prevent neural tube defects. Vitamin E needs remain at 15 mg/day, protein increases slightly to 1.1 g/kg/day (not doubled), and calcium needs stay at 1000 mg/day due to enhanced absorption, not requiring an increase.
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.