Nokea
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation.
- A. She may be experiencing postpartum preeclampsia.
- B. She may have an infection that needs further evaluation.
- C. Her symptoms could indicate anemia due to blood loss.
- D. She may be experiencing normal postpartum fatigue.
Correct Answer: A
Rationale: Symptoms like headache, visual disturbances, and nausea suggest postpartum preeclampsia, unlike infection, anemia, or normal fatigue, which don't typically include these signs.
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History and Physical:
Laboratory Results:
The client is a 24-year-old pregnant woman. She is gravida 2, para 1 (G2P1). Her mother has a history of type 2 diabetes mellitus.
Which is likely causing this client's increased blood glucose at 28 weeks? Select all that is apply.
- A. Fetal health problems
- B. Decreased cortisol
- C. Increased insulin needs
- D. Placental infection
- E. Normal weight gain of pregnancy
- F. Fetus with macrosomia
Correct Answer: C,E,F
Rationale: Increased insulin needs, normal weight gain, and macrosomia contribute to insulin resistance and hyperglycemia in pregnancy, unlike fetal health issues, decreased cortisol, or placental infection.
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
- A. Start oxytocin infusion immediately.
- B. Begin oxytocin 4 hours after misoprostol is given.
- C. Ambulate the client after administration of misoprostol.
- D. Administer misoprostol every 2 hours.
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Heart rate of 56 beats/minute.
- B. Saturating two perineal pads per hour.
- C. Soft, spongy fundus.
- D. Unilateral lower leg pain.
Correct Answer: A
Rationale: Bradycardia (56 beats/minute) is normal postpartum due to increased stroke volume, unlike excessive bleeding, uterine atony, or DVT signs.
When is the best time to administer a rubella vaccine to a client?
- A. After the client reaches 20-weeks gestation.
- B. Immediately, at 6-weeks gestation, to protect this fetus.
- C. Early postpartum, within 72 hours after delivery.
- D. After the client stops breastfeeding.
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.