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A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?
- A. Check the status of the fetal heart rate.
- B. Turn the client to her right side.
- C. Test the leaking fluid with nitrazine paper.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: Checking the fetal heart rate is the first action to ensure fetal well-being.
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A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.
A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following?
- A. Conjunctivitis.
- B. Heart disease.
- C. Skin lesions.
- D. Hepatitis.
Correct Answer: A
Rationale: Untreated chlamydia during delivery can cause neonatal conjunctivitis (ophthalmia neonatorum) via transmission through the birth canal. Heart disease, skin lesions, and hepatitis are not associated with chlamydia.
A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should prepare to do which of the following?
- A. Transfer the client to the antenatal unit.
- B. Keep the client NPO for 24 hours.
- C. Administer magnesium sulfate.
- D. Obtain an ultrasound.
Correct Answer: D
Rationale: Ultrasound confirms the diagnosis of a hydatidiform mole.
The nurse is caring for a multigravid client at 34 weeks' gestation diagnosed with preterm labor. The client has delivered two stillborn infants at 30 weeks' gestation. The client is scheduled for a sonogram before an amniocentesis. Which of the following would be a priority nursing diagnosis for the client?
- A. Acute pain related to abnormal uterine contractions.
- B. Anxiety related to diagnostic tests for fetal well-being.
- C. Ineffective coping related to hospitalization.
- D. Deficient knowledge related to consequences of preterm birth.
Correct Answer: B
Rationale: Anxiety related to diagnostic tests is a priority.
Fifteen minutes after a client experiences an eclamptic seizure, the nurse should assess the client for which of the following?
- A. Polyuria.
- B. Facial flushing.
- C. Hypotension.
- D. Uterine contractions.
Correct Answer: D
Rationale: Uterine contractions should be assessed post-seizure to evaluate labor status.