Nokea
A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery?
- A. Cephalopelvic disproportion and hypothermia
- B. Asphyxia and meconium aspiration
- C. Intraventricular hemorrhage and dry,cracked skin
- D. Hyperbilirubinemia and hypocalcemia
Correct Answer: B
Rationale: The correct answer is B: Asphyxia and meconium aspiration. At 42 weeks gestation, the risk of perinatal asphyxia increases due to decreased placental function. Meconium aspiration can occur if the fetus passes stool in utero, leading to respiratory distress. The other choices are not directly related to postterm pregnancy complications. Cephalopelvic disproportion and hypothermia (Choice A) are not specific to postterm pregnancy. Intraventricular hemorrhage and dry, cracked skin (Choice C) are not commonly associated with postterm pregnancies. Hyperbilirubinemia and hypocalcemia (Choice D) are more likely to occur after birth and are not directly related to being postterm.
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A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because removing the condom 30 minutes after intercourse is incorrect. Condoms should be removed immediately after ejaculation to prevent leakage or spillage of semen. Leaving the condom on for too long increases the risk of pregnancy and STIs. Choice A is correct as putting the condom on while the penis is erect is the proper way to ensure it fits securely. Choice C is also correct as leaving a small space at the tip allows room for semen collection. Choice D is incorrect because spermicidal gels or creams are not recommended with condoms as they can cause irritation and may not increase effectiveness.
A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains?
- A. Infection of the suture line
- B. Constipation and bloating
- C. Contractions of the uterus
- D. Trauma during delivery
Correct Answer: C
Rationale: The correct answer is C: Contractions of the uterus. After giving birth, the uterus continues to contract to reduce in size, which can cause cramping or afterpains. This is a normal process known as involution. Infection of the suture line (A) would present with other symptoms like redness, swelling, and warmth. Constipation and bloating (B) may cause discomfort but are not directly related to afterpains. Trauma during delivery (D) could lead to pain but is not the main cause of afterpains in a breastfeeding mother.
For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?
- A. Hemoglobin 10.2 mg/dL and uterine tenderness
- B. Polyuria and weight loss of 3 pounds in the last month
- C. Blood pressure 168/110 and 3+ proteinuria
- D. Hematuria and blood glucose of 160 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 168/110 and 3+ proteinuria. Pregnancy-induced hypertension (PIH) is characterized by high blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg) and proteinuria. In this case, the blood pressure reading of 168/110 indicates hypertension, and 3+ proteinuria indicates significant protein in the urine, both of which are key diagnostic criteria for PIH.
A: Hemoglobin 10.2 mg/dL and uterine tenderness - These are not specific indicators of PIH.
B: Polyuria and weight loss of 3 pounds in the last month - These symptoms are not typically associated with PIH.
D: Hematuria and blood glucose of 160 mg/dL - Hematuria suggests blood in the urine, which is not a typical finding in PIH, and elevated blood glucose is more indicative of diabetes rather than PIH.
Therefore,
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client
- B. Instruct the client to schedule an annual pelvic examination
- C. Tell the client she will start medication for HIV immediately after delivery
- D. Report the client’s condition to the local health department
Correct Answer: D
Rationale: Rationale: Reporting the client's HIV positive status to the local health department is crucial for monitoring and preventing the spread of the infection. This action ensures proper follow-up care, contact tracing, and support services for the client and at-risk individuals. Administering penicillin G (choice A) is not indicated for HIV positive status. Instructing the client to schedule a pelvic examination (choice B) is unrelated to the client's HIV status. Delaying HIV medication until after delivery (choice C) can pose risks to both the mother and the baby.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms, including gastrointestinal issues like vomiting. This is due to the sudden absence of the drug after birth. Choices A, B, and C are unrelated to SSRI withdrawal. Large for gestational age is more indicative of maternal diabetes, hyperglycemia is not a typical SSRI withdrawal symptom, and bradypnea is not commonly associated with SSRI use.