Nokea
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?
- A. striae gravidarum
- B. linea nigra
- C. vascular spiders
- D. melasma
Correct Answer: B
Rationale: Linea nigra is a dark line from umbilicus to pubis caused by increased melanin from hormonal changes. Striae gravidarum are stretch marks, vascular spiders are dilated vessels on face or chest, and melasma is facial pigmentation, none matching the abdominal line description.
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A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?
- A. Hemorrhage
- B. Edema
- C. Infection
- D. Jaundice
Correct Answer: A
Rationale: A ruptured ectopic pregnancy causes internal bleeding, leading to hypovolemic shock, making hemorrhage the priority assessment. Edema, infection, or jaundice may occur later but are less urgent than life-threatening bleeding.
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?
- A. clear liquid diet
- B. administration of diethylstilbestrol
- C. total parenteral nutrition
- D. nothing by mouth
Correct Answer: C
Rationale: Hyperemesis gravidarum causes severe vomiting, risking dehydration and malnutrition. Total parenteral nutrition delivers complete nutrients intravenously, addressing these risks when oral intake fails. Clear liquids or nothing by mouth worsen malnutrition, and diethylstilbestrol, a discontinued drug, is irrelevant.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?
- A. Vitamin E requirements decrease during pregnancy due to the increase in body fat.
- B. Prenatal vitamins will meet your need for increased folic acid during pregnancy.
- C. You will need to double your intake of protein during pregnancy.
- D. You will need to increase your intake of calcium during pregnancy.
Correct Answer: B
Rationale: Prenatal vitamins provide 600 mcg/day folic acid, meeting pregnancy needs to prevent neural tube defects. Vitamin E needs remain at 15 mg/day, protein increases slightly to 1.1 g/kg/day (not doubled), and calcium needs stay at 1000 mg/day due to enhanced absorption, not requiring an increase.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
- A. I'm sorry you lost your baby.
- B. Why are you crying?
- C. Will a pill help your pain?
- D. A baby still wasn't formed in your womb.
Correct Answer: A
Rationale: Saying 'I'm sorry you lost your baby' acknowledges the client's emotional loss empathetically. Asking why she's crying invalidates her feelings, focusing on physical pain ignores emotional needs, and claiming the baby wasn't formed is inaccurate and insensitive, as miscarriage involves loss at any stage.
A nurse is preparing to administer chlordiazepoxide 50 mg PO every 8 hours to a client. The amount available is chlordiazepoxide 25 mg per capsule. How many capsules should the nurse administer per dose?
- A. 2 capsules
- B. 1 capsule
- C. 3 capsules
- D. 4 capsules
Correct Answer: A
Rationale: Dose (50 mg) / concentration (25 mg/capsule) = 2 capsules per dose. Other options miscalculate the number needed to achieve 50 mg.