Nokea
An adolescent primiparous client at 24 hours postpartum tells the nurse that she and her baby will be living with her boyfriend's parents so that she can finish high school and go on to college. The client's boyfriend and parents have been supportive of the client and neonate. Which of the following is an appropriate nursing diagnosis at this time?
- A. Anxiety related to return to high school and peer pressure.
- B. Ineffective coping related to inability to view motherhood realistically.
- C. Readiness for enhanced family coping, related to the addition of a new family member.
- D. Deficient knowledge related to the financial and emotional costs of childrearing.
Correct Answer: C
Rationale: The supportive environment suggests readiness for enhanced family coping, which is appropriate given the positive family dynamics.
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When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which of the following fetal systems?
- A. Urinary.
- B. Gastrointestinal.
- C. Cardiovascular.
- D. Pulmonary.
Correct Answer: D
Rationale: The shake test evaluates pulmonary maturity.
The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
- A. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine.
- B. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly.
- C. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.
- D. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.
Correct Answer: C
Rationale: Severe preeclampsia requires immediate attention.
When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation(DIC)?
- A. Ringer's lactate solution.
- B. Fresh frozen platelets.
- C. 5% dextrose solution.
- D. Warfarin sodium(Coumadin).
Correct Answer: B
Rationale: Fresh frozen platelets are used to manage bleeding in DIC.
The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following should the nurse instruct the parents to do because of the neonate's infection?
- A. Use caution near the isolation incubator and equipment.
- B. Visit but do not touch the neonate.
- C. Wash their hands thoroughly before touching the neonate.
- D. Wear a mask when holding the neonate.
Correct Answer: C
Rationale: Thorough hand washing is critical to prevent further infection in a neonate with sepsis.
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?
- A. Firm fundus at the symphysis.
- B. White, thick vaginal discharge.
- C. Striae that are silver in color.
- D. Soft breasts without milk.
Correct Answer: B
Rationale: White, thick vaginal discharge at 6 weeks suggests an infection, as lochia should be minimal or absent by this time.