Nokea
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.
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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 multigravid client at 40 weeks' gestation with a history of previous cesarean delivery is admitted for a trial of labor. The fetal monitor shows late decelerations. Which interventions should the nurse perform? Select all that apply.
- A. Administer oxygen at 8–10 L/min via mask.
- B. Stop the oxytocin infusion.
- C. Reposition the client to her right side.
- D. Increase the IV fluid rate.
- E. Apply a fetal scalp electrode.
Correct Answer: A,B,D
Rationale: Late decelerations suggest uteroplacental insufficiency. Administering oxygen, stopping oxytocin (if running), and increasing IV fluids improve fetal oxygenation and uterine perfusion. Right-side repositioning is less effective than left-side, and scalp electrodes are not the first step.
A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. Which of the following nursing diagnoses would be the priority for this neonate?
- A. Impaired skin integrity related to post-term status.
- B. Imbalanced nutrition: More than body requirements related to large size.
- C. Risk for impaired parent-infant-child attachment related to transfer to the intensive care unit.
- D. Impaired gas exchange related to the effects of respiratory distress.
Correct Answer: D
Rationale: Impaired gas exchange is the priority due to the respiratory distress associated with meconium aspiration syndrome.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
A 24-year-old client, G 3, P 1, at 32 weeks' gestation, is admitted to the hospital because of vaginal bleeding. After reviewing the client's history, which of the following factors might lead the nurse to suspect abruptio placentae?
- A. Several hypotensive episodes.
- B. Previous low transverse cesarean delivery.
- C. One induced abortion.
- D. History of cocaine use.
Correct Answer: D
Rationale: Cocaine use is a risk factor for abruptio placentae.