Nokea
After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching?
- A. "I should avoid being near people who have a cold."
- B. "I may be given antibiotics during my pregnancy."
- C. "I should reduce my intake of protein in my diet."
- D. "I should limit my salt intake at meals."
Correct Answer: C
Rationale: Reducing protein intake is not recommended for clients with heart disease.
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A multigravid client is receiving oxytocin (Pitocin) augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which of the following actions should the nurse do first?
- A. Increase the rate of the oxytocin infusion.
- B. Turn the client to a knee-to-chest position.
- C. Assess cervical dilation and effacement.
- D. Monitor the fetal heart rate continuously.
Correct Answer: D
Rationale: Meconium-stained fluid indicates potential fetal distress, requiring immediate continuous fetal heart rate monitoring to assess for complications like cord compression or hypoxia. Increasing oxytocin, repositioning, or reassessing dilation are secondary.
A client is considering the fertility awareness method. Which of the following client statements indicates understanding?
- A. I will track my basal body temperature daily.
- B. I can use this method with irregular cycles.
- C. I will monitor ovulation with a pregnancy test.
- D. I will avoid intercourse throughout the cycle.
Correct Answer: A
Rationale: Tracking basal body temperature daily is a key component of the fertility awareness method. It is less reliable with irregular cycles, pregnancy tests do not monitor ovulation, and intercourse is avoided only during fertile periods.
After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?
- A. Hydrocephalic infant.
- B. Abruptio placentae.
- C. Intrauterine growth retardation.
- D. Poor placental perfusion.
Correct Answer: A
Rationale: Preeclampsia does not typically cause hydrocephalus.
Before surgery to remove an ectopic pregnancy and the fallopian tube, which of the following would alert the nurse to the possibility of tubal rupture?
- A. Amount of vaginal bleeding and discharge.
- B. Falling hematocrit and hemoglobin levels.
- C. Slow, bounding pulse rate of 80 bpm.
- D. Marked abdominal edema.
Correct Answer: B
Rationale: Falling hematocrit and hemoglobin levels indicate internal bleeding.
After administering hydralazine(Apresoline) 5 mg intravenously as ordered for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:
- A. Tachycardia.
- B. Bradypnea.
- C. Polyuria.
- D. Dysphagia.
Correct Answer: A
Rationale: Tachycardia is a potential side effect of hydralazine.