Nokea
A primigravid client's baseline blood pressure at her initial visit at 12 weeks' gestation was 110/70 mm Hg. During an assessment at 38 weeks' gestation, which of the following data would indicate mild preeclampsia?
- A. Blood pressure of 160/110 mm Hg on two separate occasions.
- B. Proteinuria, more than 5 g in 24 hours.
- C. Serum creatinine concentration of 1.4 mL/dL.
- D. Weight gain of 2 lb in the last week.
Correct Answer: D
Rationale: Sudden weight gain is characteristic of mild preeclampsia.
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A client asks about the disadvantages of oral contraceptives. Which of the following would the nurse include?
- A. They must be taken at the same time daily for maximum effectiveness.
- B. They provide long-term contraception for up to 5 years.
- C. They are highly effective without side effects.
- D. They protect against STIs.
Correct Answer: A
Rationale: Oral contraceptives must be taken at the same time daily for maximum effectiveness, as timing affects hormone levels. They are short-term (daily), have potential side effects, and do not protect against STIs.
The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client panting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
- A. Tell the client to push between contractions.
- B. Provide gentle support to the fetal head.
- C. Apply gentle upward traction on the neonate's anterior shoulder.
- D. Massage the perineum to stretch the perineal tissues.
Correct Answer: B
Rationale: With the fetal head crowning, providing gentle support prevents rapid expulsion and perineal trauma. Pushing between contractions is incorrect, traction is for shoulder dystocia, and perineal massage is less urgent.
A primigravid client in active labor with a fetus in LOP position complains of severe back pressure. Which of the following would be the priority nursing diagnosis for this client?
- A. Anxiety related to fear of maternal-fetal outcomes.
- B. Ineffective coping related to lack of experience in labor.
- C. Urinary retention related to prolonged labor process.
- D. Pain related to occipitoposterior position and prolonged fetal descent.
Correct Answer: D
Rationale: Severe back pain due to the LOP position is a priority, as it impacts the client's comfort and labor experience. Pain management (e.g., counterpressure) is critical. Anxiety, coping, and urinary retention are secondary concerns.
A 24-hour-old, full-term neonate is showing signs and possible signs. The nurse is assisting the physician with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply.
- A. Administer the I.V. antibiotic.
- B. Hold the neonate steady in the correct position.
- C. Ensure a patent airway.
- D. Maintain a sterile field.
- E. Obtain a serum glucose level.
Correct Answer: B,C,D
Rationale: Holding the neonate steady, ensuring a patent airway, and maintaining a sterile field are critical during a lumbar puncture to ensure safety and procedure success.
While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
- A. Turn the client to the right side.
- B. Assess the color, amount, and odor of the fluid.
- C. Assess the fetal heart rate pattern.
- D. Check the client's cervical dilation.
Correct Answer: C
Rationale: Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.