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Nurses' Notes: Client at 28 weeks, gravida 4, para 3, vaginal bleeding for 2 hr, saturating pads with bright red blood, no abdominal pain. Abdomen soft, nontender, fundal height 27 cm, FHR 170/min with minimal variability. Vital Signs: Temp 36.6°C, HR 120/min, RR 22/min, BP 86/48 mm Hg, O2 sat 96%. Diagnostic Results: Hct 25%, Hgb 9 g/dL, Platelet 110,000/mm3, WBC 12,000/mm3, Blood type B+.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
- A. Monitor administration of ampicillin 2g IV bolus, Reinforce with the client to maintain bed rest, Administer methotrexate, Insert a large bore peripheral IV cathete, Assist the client with positioning for a vaginal examination
- B. Ectopic pregnancy, Placenta Previa, Cervical insufficiency, Chorioamnionitis
- C. Cervical dilatation, Vaginal bleeding, Fetal wellbeing, WBC count, Beta human chorionic gonadotropin levels
Correct Answer: A
Rationale: Painless, bright red bleeding at 28 weeks suggests placenta previa. Bed rest minimizes bleeding risk, and IV access prepares for fluid resuscitation. Monitoring bleeding and fetal well-being assesses stability.
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Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever
- B. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup sweet white corn
- B. 1 cup kale
- C. 1 baked potato
- D. 1 large banana
Correct Answer: B
Rationale: Kale is a rich plant-based source of calcium, providing approximately 90 mg per cup, ideal for those avoiding dairy.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will lay my baby on a pillow at the level of my breast.
- D. I will apply vitamin E oil to my nipples after each feeding.
Correct Answer: C
Rationale: Positioning the baby at breast level with a pillow promotes a comfortable latch and effective feeding.