Nokea
A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.)
- A. Tell the husband that authorities will be notified immediately.
- B. Provide privacy for the assessment.
- C. Determine if children are being hurt.
- D. Communicate in a nonjudgmental way.
- E. Determine factors that increase the risk of injury.
Correct Answer: B,C,D,E
Rationale: The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The nurse also determines whether children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she intends to leave.
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The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient?
- A. To prevent convulsions
- B. To promote diaphoresis
- C. To increase reflex irritability
- D. To act as a saline cathartic
Correct Answer: A
Rationale: Magnesium sulfate is a central nervous system depressant given to prevent seizures.
A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness?
- A. Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
- B. Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
- C. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
- D. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.
Correct Answer: B
Rationale: Dehydration and electrolyte imbalances result from persistent nausea and vomiting associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta.
A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism in what way?
- A. Placental hormones increase the resistance of cells to insulin.
- B. Insulin cells cannot meet the body's demands as the woman's weight increases.
- C. There is a decreased production of insulin during pregnancy.
- D. The speed of insulin breakdown is decreased during pregnancy.
Correct Answer: A
Rationale: Hormones and enzymes produced by the placenta increase the resistance of cells to insulin.
The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the highest priority nursing intervention?
- A. Count respirations and report a rate of less than 12 breaths/minute.
- B. Count respirations and report a rate of more than 20 breaths/minute.
- C. Check blood pressure and report a rate of less than 100/60 mm Hg.
- D. Monitor urinary output and report a rate of less than 100 mL/hr.
Correct Answer: A
Rationale: Excessive magnesium sulfate may cause respiratory depression.
The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection for what reasons? (Select all that apply.)
- A. Vaginal organisms can invade the placenta.
- B. The undernourished placenta becomes necrotic.
- C. The amniotic fluid can become infected.
- D. The placenta is an excellent growth medium.
- E. The misplaced placenta weakens the uterine wall.
Correct Answer: A,D
Rationale: Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the nutrient-rich environment of the placenta. The weak musculature of the lower segment of the uterus will cause postpartum hemorrhage rather than infection.