Nokea
A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.
- A. Ultrasound visualization of the fetus
- B. Softening of the cervix
- C. Positive pregnancy test
- D. Absence of menstruation
- E. Ballottement
- F. Auscultation of a fetal heart beat
Correct Answer: B,C,D,E
Rationale: Probable signs include softening of the cervix (Goodell's), positive pregnancy test (hCG), amenorrhea, and ballottement (fetal rebound). Ultrasound and fetal heartbeat are positive signs, confirming pregnancy definitively.
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A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through mosquitoes.
- B. It is primarily transmitted through accidental puncture wounds.
- C. It is primarily transmitted through casual contact.
- D. It is primarily transmitted through direct contact with infected body fluids.
Correct Answer: D
Rationale: HIV spreads mainly through direct contact with infected fluids (blood, semen, vaginal fluid), like during sex or needle sharing. Mosquitoes, casual contact, and puncture wounds (rare) aren't primary modes.
A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply.
- A. Cloudy malodorous fluid
- B. Abdominal tenderness
- C. Fetal bradycardia
- D. Elevated maternal pulse rate
- E. Decreased C-reactive protein levels
Correct Answer: A,B,C,D
Rationale: Infection after membrane rupture shows as cloudy, foul fluid (bacterial contamination), abdominal tenderness (inflammation), fetal bradycardia (distress), and elevated pulse (systemic response). Decreased C-reactive protein doesn't indicate infection; it rises with inflammation.
A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?
- A. Wear spandex-type full-length pants
- B. Try elevating your legs when you sit
- C. Limit your intake of fluids
- D. Eliminate salt from your diet
Correct Answer: B
Rationale: Elevating legs reduces swelling by aiding venous return, a safe intervention for late-pregnancy edema. Tight pants worsen swelling, limiting fluids risks dehydration, and eliminating salt disrupts electrolytes.
It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
- A. 24 hours before delivery and 24 hours after delivery
- B. In the first trimester and within 2 hours of delivery
- C. At 28 weeks gestation and again within 72 hours after delivery
- D. At 32 weeks gestation and immediately before discharge
Correct Answer: C
Rationale: Rho(D) immune globulin at 28 weeks and within 72 hours post-delivery prevents Rh isoimmunization by neutralizing fetal Rh-positive cells. Earlier or later timing risks ineffective prevention or antibody formation.
A nurse is preparing to infuse 1 liter of 0.9% sodium chloride IV over 8 hr with a tubing set that delivers 15 gtts/mL. The nurse should set the manual IV infusion to deliver how many drops/min?
- A. 31 gtts/min
- B. 30 gtts/min
- C. 32 gtts/min
- D. 29 gtts/min
Correct Answer: A
Rationale: Formula: gtts/min = (volume x drop factor) / time. (1000 mL x 15 gtts/mL) / (8 x 60 min) = 15000 / 480 = 31.25, rounded to 31 gtts/min. Other options miscalculate the rate.