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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.
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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 healthcare provider is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the provider include in the teaching? (Select all that apply)
- A. Weight fluctuations can occur.
- B. Irregular vaginal spotting can occur.
- C. You should increase your intake of calcium.
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all options are relevant when teaching a client about medroxyprogesterone. A, weight fluctuations can occur due to hormonal changes. B, irregular vaginal spotting is a common side effect of medroxyprogesterone. C, increasing calcium intake is important to prevent bone density loss associated with long-term medroxyprogesterone use. Therefore, all options are essential for comprehensive client education. Other choices are incorrect because excluding any of these key points could lead to incomplete information and potential misunderstandings regarding the medication's effects and management.
A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
- A. Use a condom with sexual intercourse
- B. Avoid bubble bath solution when taking a tub bath
- C. Wipe from front to back when performing perineal hygiene
- D. Keep a daily record of fetal kick counts
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems.
A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes.
B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being.
C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.
A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?
- A. I will inform the provider that you are having these feelings.
- B. It is normal to have these feelings during the first few months of pregnancy.
- C. You should be happy that you are going to bring new life into the world.
- D. I am going to make an appointment with the counselor for you to discuss these thoughts.
Correct Answer: B
Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy.
1. Acknowledges client's emotions without judgment.
2. Validates the client's experience as common and normal.
3. Provides reassurance and support.
4. Encourages open communication.
Summary of Incorrect Choices:
A. Not necessary to escalate without client's consent.
C. Invalidates client's feelings and imposes expectations.
D. Implies assumption of severity and may be seen as intrusive.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?
- A. Allow the sibling to hold the newborn during a bath.
- B. Make sure the sibling kisses the newborn each night.
- C. Obtain a gift from the newborn to present to the sibling.
- D. Switch the sibling's room with the nursery.
Correct Answer: C
Rationale: The correct answer is C: Obtain a gift from the newborn to present to the sibling. This suggestion helps foster acceptance and bonding between the siblings by creating a positive association and sense of reciprocity. It allows the 7-year-old to feel included and appreciated in the new family dynamic.
Explanation of why the other choices are incorrect:
A: Allowing the sibling to hold the newborn during a bath may not be safe or appropriate, and could potentially lead to accidents or discomfort for the newborn.
B: Forcing physical affection like kissing may not be well-received by the sibling and could create negative feelings towards the newborn.
D: Switching the sibling's room with the nursery could disrupt the sibling's sense of stability and security, potentially causing confusion and anxiety.