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The nurse is caring for a client with a suspected hydatidiform mole. Based on the diagnosis, what does the nurse anticipate? Select all that apply.
- A. Dark brown vaginal bleeding
- B. Strong fetal heart tones
- C. Fundal height larger than expected
- D. Elevated blood pressure
Correct Answer: B
Rationale: Step-by-step rationale:
1. Hydatidiform mole is a type of gestational trophoblastic disease.
2. It results in the abnormal growth of placental tissue instead of a fetus.
3. As there is no fetus, there won't be any fetal heart tones.
4. Therefore, the nurse anticipates absence of fetal heart tones.
Summary:
A: Dark brown vaginal bleeding is not specific to hydatidiform mole.
C: Fundal height larger than expected is not a typical sign of hydatidiform mole.
D: Elevated blood pressure is not directly associated with hydatidiform mole.
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During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
- A. Orthopnea
- B. Pulmonary edema
- C. Anemia
- D. Decreased blood volume
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect suggests pulmonary edema. This is due to fluid accumulation in the lungs, leading to coughing. Pulmonary edema can occur due to increased blood volume and pressure on the heart during pregnancy, exacerbating the client's pre-existing heart condition. Orthopnea (choice A) is difficulty breathing while lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not directly linked to a nonproductive cough. Decreased blood volume (choice D) is unlikely in a pregnant client and would not explain the cough.
The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
A nurse is monitoring a client with type 2 diabetes mellitus. Her blood work reveals a glycosylated hemoglobin (HbA1c) of 10%. The nurse knows this blood work indicates which of the following?
- A. A normal value indicating that the client is managing blood glucose control well
- B. A low value indicating that the client is not managing blood glucose control very well
- C. A high value indicating that the client is not managing blood glucose control very well
- D. The value does not offer information regarding client management of her disease
Correct Answer: C
Rationale: Rationale:
1. HbA1c reflects average blood glucose levels over the past 2-3 months.
2. A value of 10% indicates poor blood glucose control.
3. High HbA1c (above 6.5-7%) signifies uncontrolled diabetes.
4. Choice C is correct as it aligns with the interpretation of HbA1c.
Summary:
- Choice A is incorrect as 10% is not a normal HbA1c value.
- Choice B is incorrect as a low value would indicate good control.
- Choice D is incorrect as HbA1c is a key marker for diabetes management.
The nurse is caring for a client with a suspected hydatidiform mole. Based on the diagnosis, what does the nurse anticipate? Select all that apply.
- A. Dark brown vaginal bleeding
- B. Strong fetal heart tones
- C. Fundal height larger than expected
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Strong fetal heart tones. In a hydatidiform mole, the pregnancy is abnormal and does not involve a fetus. Therefore, the absence of fetal heart tones is expected. Dark brown vaginal bleeding (A) is not specific to a hydatidiform mole. Fundal height larger than expected (C) and elevated blood pressure (D) are not typically associated with a hydatidiform mole.
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
- A. Having high levels of hCG
- B. Having high blood pressure
- C. Being an adolescent
- D. Being underweight
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are at higher risk for hyperemesis gravidarum due to hormonal changes and inadequate nutritional intake. Adolescents often experience rapid growth and increased nutritional demands, leading to a higher susceptibility to conditions like hyperemesis gravidarum. High levels of hCG (A) are common in pregnancy and can contribute to nausea and vomiting but are not the primary cause of hyperemesis gravidarum. High blood pressure (B) is not directly related to hyperemesis gravidarum. Being underweight (D) may exacerbate the condition but is not the primary factor causing hyperemesis gravidarum in this case.