Nokea
During a weekly prenatal visit, a nurse is assessing a client at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 136/88 mm Hg
- B. Report of insomnia
- C. Weight gain of 2.2 kg (4.8 lb)
- D. Report of Braxton-Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Weight gain of 2.2 kg (4.8 lb). This finding should be reported to the provider because sudden excessive weight gain in late pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This could indicate a potential complication that needs immediate medical attention.
Explanation:
A: Blood pressure 136/88 mm Hg - This blood pressure reading is slightly elevated but not concerning for preeclampsia at this level.
B: Report of insomnia - Insomnia is a common issue during pregnancy and not typically a cause for immediate concern.
D: Report of Braxton-Hicks contractions - Braxton-Hicks contractions are common in the third trimester and are considered normal as long as they are not regular or increasing in intensity.
You may also like to solve these questions
A healthcare professional is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the healthcare professional anticipate administering if magnesium sulfate toxicity is suspected?
- A. Nifedipine
- B. Pyridoxine
- C. Ferrous sulfate
- D. Calcium gluconate
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. When magnesium sulfate toxicity is suspected, calcium gluconate is administered because it antagonizes the effects of magnesium on the heart and central nervous system. This helps to counteract the muscle weakness, respiratory depression, and cardiac arrhythmias associated with magnesium toxicity. Nifedipine (A) is a calcium channel blocker and is not indicated for magnesium toxicity. Pyridoxine (B) is a form of vitamin B6 and is not used to treat magnesium toxicity. Ferrous sulfate (C) is an iron supplement and is not relevant in the management of magnesium toxicity.
During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?
- A. Back rub
- B. Counter-pressure
- C. Playing music
- D. Foot massage
Correct Answer: B
Rationale: The correct answer, B: Counter-pressure, is the best nonpharmacological intervention for a client with a posterior fetal head position causing lower back pain. Counter-pressure applied to the sacrum can help alleviate discomfort by reducing pressure on the lower back and providing support during contractions. This technique can aid in rotating the baby's head to a more optimal position for delivery.
Choice A: Back rub, may offer some comfort but may not specifically address the issue of lower back pain caused by the fetal position. Choice C: Playing music, and Choice D: Foot massage, are unlikely to provide direct relief for the client's specific discomfort related to the baby's posterior position.
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
- A. Hyperemesis gravidarum
- B. Threatened abortion
- C. Hydatidiform mole
- D. Preterm labor
Correct Answer: C
Rationale: The correct answer is C: Hydatidiform mole. At 4 months of gestation, prune-colored discharge indicates possible passage of vesicular tissue characteristic of a molar pregnancy. This, along with continued nausea, vomiting, and larger fundal height, are signs of a hydatidiform mole. Hyperemesis gravidarum (A) typically involves severe nausea and vomiting leading to weight loss, which the client did not experience. Threatened abortion (B) presents with vaginal bleeding and cramping, not prune-colored discharge. Preterm labor (D) is characterized by regular contractions leading to cervical changes, not the symptoms described.
A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?
- A. Persistent abdominal striae
- B. Temperature 37.8° C (100.2° F)
- C. Unilateral breast pain
- D. Brownish-red discharge on day 5
Correct Answer: C
Rationale: Rationale: Unilateral breast pain in a postpartum client can indicate mastitis, a bacterial infection of the breast tissue. This requires prompt medical attention to prevent complications like abscess formation.
Other Choices:
A: Abdominal striae are normal after pregnancy and don't require immediate intervention.
B: Mild temperature elevation is common postpartum and doesn't necessarily indicate infection.
D: Brownish-red discharge on day 5 is typically normal lochia and not concerning unless foul-smelling or accompanied by fever.