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A client with a history of hypertension is at 28 weeks' gestation. What complication is she at greatest risk for?
- A. Placenta previa.
- B. Gestational diabetes.
- C. Abruptio placentae.
- D. Preterm labor.
Correct Answer: C
Rationale: The correct answer is C: Abruptio placentae. At 28 weeks, the client with hypertension is at greater risk for abruptio placentae due to increased vascular resistance, leading to potential placental detachment. Placenta previa (A) is more common in the third trimester. Gestational diabetes (B) is more common in later pregnancy and not directly related to hypertension. Preterm labor (D) can be a risk with chronic hypertension but is not the greatest risk at 28 weeks.
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The nurse is reviewing a prenatal chart and notes a client with placenta previa. What is the priority nursing consideration?
- A. Encourage vaginal delivery.
- B. Avoid vaginal examinations.
- C. Encourage bed rest at home.
- D. Prepare for immediate induction of labor.
Correct Answer: B
Rationale: The correct answer is B: Avoid vaginal examinations. Placenta previa is a condition where the placenta partially or completely covers the cervix, increasing the risk of bleeding. Vaginal examinations can trigger bleeding by disrupting the placenta. The priority is to minimize the risk of bleeding and prevent complications. Encouraging vaginal delivery (A) is contraindicated due to the risk of hemorrhage. Bed rest at home (C) may be recommended but is not the priority. Immediate induction of labor (D) can be dangerous and is not indicated unless there is an emergency situation.
A client at 36 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Cholestasis of pregnancy.
- B. Preeclampsia.
- C. Gestational diabetes.
- D. Intrauterine growth restriction.
Correct Answer: A
Rationale: The correct answer is A: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 36 weeks' gestation is often indicative of cholestasis of pregnancy, a liver condition that can occur during pregnancy. This condition is characterized by reduced bile flow, leading to the accumulation of bile acids in the blood, resulting in itching, especially on the palms and soles of the feet. Other choices (B) Preeclampsia, (C) Gestational diabetes, and (D) Intrauterine growth restriction are not typically associated with severe itching without a rash in the absence of other specific symptoms. Preeclampsia presents with hypertension and proteinuria, gestational diabetes with high blood sugar levels, and intrauterine growth restriction with poor fetal growth.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used to induce ovulation in women experiencing infertility. Breast tenderness is a common adverse effect due to the hormonal changes caused by the medication. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly associated with ototoxic medications, urinary frequency may be seen with diuretics, and chills are usually a symptom of infections or fevers.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
- A. Notify the health care provider of the findings.
- B. Reposition the mother and check the monitor for changes in the fetal tracing.
- C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
- D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. This is the most appropriate action because episodic accelerations in fetal heart rate patterns are a reassuring sign of fetal well-being. By documenting the findings and informing the mother of this, the nurse can provide reassurance and promote a positive birthing experience.
Choice A is incorrect because notifying the health care provider is not necessary for this normal finding. Choice B is incorrect because repositioning the mother and checking the monitor for changes is not needed when episodic accelerations are present. Choice C is incorrect because taking the mother's vital signs and prescribing bed rest is unnecessary and not indicated based on the fetal heart rate pattern.
People in extended families can live together for many reasons. What can the nurse do to provide the best care for a person living with an extended family?
- A. Assume the family is poor and needs information on financial assistance.
- B. Ask the person if they would like the family members to remain in the room during the exam.
- C. Set a limit on who is allowed in the room with the person regardless of the circumstances.
- D. Address the family first then the patient.
Correct Answer: B
Rationale: The correct answer is B because it respects the person's autonomy and preferences by asking if they want family members present during the exam. This approach ensures the person's comfort and privacy while also promoting family involvement in care. Choice A assumes financial need without evidence. Choice C limits family support. Choice D may neglect the person's immediate needs.