Nokea
Client at first prenatal visit
Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.
- A. Breast tenderness
- B. Nausea and vomiting
- C. Quickening
- D. Goodell's sign
- E. Striae gravidarum
- F. Lightening
Correct Answer: A,B,C,D,E,F
Rationale: The correct order is A, B, C, D, E, F. Firstly, breast tenderness (A) typically occurs early in pregnancy due to hormonal changes. Next, nausea and vomiting (B) often start around the 6th week. Quickening (C), the first fetal movements felt by the mother, occurs around 16-20 weeks. Goodell's sign (D), softening of the cervix, happens around the 6th-8th week. Striae gravidarum (E), stretch marks, appear later in pregnancy due to skin stretching. Finally, lightening (F), when the baby drops lower in the pelvis, occurs in the last few weeks before labor. Other options are incorrect as they do not follow the chronological order of gestation milestones.
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Client just learned she is pregnant
The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?
- A. Decreased energy
- B. Mood swings
- C. Urinary frequency
- D. Facial edema
Correct Answer: D
Rationale: The correct answer is D: Facial edema. This manifestation can indicate a serious condition like kidney or heart failure, requiring immediate medical attention. Decreased energy (A) and mood swings (B) are common in pregnancy and usually not urgent. Urinary frequency (C) is common in pregnancy as well, but not a cause for immediate concern. Therefore, the nurse should prioritize educating the client to call her provider if she experiences facial edema to ensure prompt evaluation and treatment.
Client 4 hours postpartum, vaginal birth, saturated perineal pad within 10 minutes
Which of the following is the nurse's first action?
- A. Observe for pooling of blood under the buttocks.
- B. Assess client's blood pressure.
- C. Prepare to administer a prescribed oxytocic preparation.
- D. Massage the client's fundus.
Correct Answer: D
Rationale: The correct answer is D: Massage the client's fundus. This is the nurse's first action after childbirth to prevent postpartum hemorrhage by promoting uterine contractions and expelling any clots. Assessing blood pressure (B) is important but not the first action. Observing for pooling of blood under the buttocks (A) is a sign of excessive bleeding but not the first action. Administering oxytocic preparation (C) can help prevent postpartum hemorrhage, but it is not the first action.
Client at 34 weeks of gestation, at risk for placental abruption
Which of the following is the most common risk factor for a placental abruption?
- A. Maternal battering
- B. Maternal cigarette smoking
- C. Maternal hypertension
- D. Maternal cocaine use
Correct Answer: C
Rationale: The correct answer is C: Maternal hypertension. Placental abruption is the premature separation of the placenta from the uterus before delivery. Hypertension can lead to reduced blood flow to the placenta, increasing the risk of abruption. Maternal battering (A) can cause trauma but is not the most common risk factor. Maternal cigarette smoking (B) and cocaine use (D) can also increase the risk but are not as prevalent as hypertension. Other factors may include advanced maternal age, multiple pregnancies, and previous history of placental abruption.
Client pregnant, taking iron supplements for iron-deficiency anemia, reports black stools, no abdominal pain or cramping
Which of the following responses by the nurse is appropriate?
- A. What else have you been eating?
- B. Go to the emergency room and your provider will meet you there.
- C. This is expected because of the way iron is broken down during digestion.
- D. Come to the office and we will check things out.
Correct Answer: C
Rationale: The correct answer is C because it provides an appropriate explanation for the situation. Iron is known to cause dark stools due to its breakdown in the digestive system. This response shows understanding and reassures the patient. Choice A is relevant but doesn't address the specific issue. Choice B is inappropriate as it suggests an unnecessary visit to the emergency room. Choice D is a general invitation without addressing the concern.
Client in second trimester, new diagnosis of gestational diabetes
Which statement by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will take my glyburide daily with breakfast.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I know I am at increased risk to develop type 2 diabetes.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week contradicts the importance of regular physical activity in managing diabetes. Regular exercise helps improve insulin sensitivity and control blood sugar levels. Limiting carbohydrates to 50% of caloric intake (choice A) is a recommended dietary guideline for diabetes management. Taking glyburide daily with breakfast (choice B) indicates adherence to medication therapy. Knowing about the increased risk of developing type 2 diabetes (choice D) shows awareness of the condition.