Nokea
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
- A. Urinary tract infection
- B. High output renal failure
- C. Excessive use of IV fluids during delivery
- D. Normal diuresis after delivery
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, diuresis is common due to the body eliminating excess fluid retained during pregnancy. This process helps reduce swelling and aids in returning to pre-pregnancy state. Voiding 2,000 mL in the first twelve hours is within the expected range for postpartum diuresis. Choices A, B, and C are incorrect as they do not align with the typical physiologic response to childbirth. Urinary tract infection and high output renal failure would present with other symptoms, while excessive IV fluid use would not explain the timing or volume of urine output.
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With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy?
- A. You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar.
- B. Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby.
- C. There is a good possibility you will be taking insulin for the rest of your life.
- D. You should eat three large meals per day to maintain steady glucose load.
Correct Answer: B
Rationale: The correct answer is B: Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby. During pregnancy, the placenta produces hormones that can make it difficult for insulin to work effectively, leading to gestational diabetes. Insulin helps to lower blood sugar levels in the mother, which in turn provides the necessary glucose for the developing baby's growth and development. The other choices are incorrect because: A) Oral hypoglycemics are not typically prescribed during pregnancy due to potential risks to the baby. C) Gestational diabetes usually resolves after delivery and does not require lifelong insulin use. D) Eating three large meals per day can cause blood sugar spikes and is not recommended for managing gestational diabetes.
At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician?
- A. Fetal heart rate averaging 160 beats/min
- B. Irregular contractions every 15-20 minutes that last 30 seconds before stopping
- C. Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70
- D. Ferning pattern of vaginal discharge under a microscope
Correct Answer: D
Rationale: The correct answer is D - Ferning pattern of vaginal discharge under a microscope. This finding indicates rupture of membranes which can lead to infection and necessitates immediate medical attention to prevent harm to the fetus and mother. A: Fetal heart rate of 160 bpm is within normal range. B: Irregular contractions every 15-20 minutes are not indicative of active labor. C: Maternal vital signs are within normal limits and do not pose an immediate threat.
For a pregnant adolescent who is anemic, which foods should the nurse include in the client's dietary plan to increase iron levels?
- A. Milk and fish
- B. Chicken and cottage cheese
- C. Orange juice and apricots
- D. Pickles and peanut butter sandwiches
Correct Answer: C
Rationale: The correct answer is C: Orange juice and apricots. Orange juice is a good source of Vitamin C, which enhances iron absorption. Apricots are high in iron, helping to increase iron levels in the body. Milk and fish (choice A) contain little iron. Chicken and cottage cheese (choice B) are not significant sources of iron. Pickles and peanut butter sandwiches (choice D) lack iron and Vitamin C.
A women in her first trimester contracts rubella. How is the fetus likely to be affected?
- A. Reproductive and urinary defects
- B. Heart defects and cataracts
- C. Spinal cord and skeletal defects
- D. Polydactyly and club feet
Correct Answer: B
Rationale: The correct answer is B: Heart defects and cataracts. Rubella infection during the first trimester can lead to congenital rubella syndrome, causing heart defects and cataracts in the fetus. Rubella affects organ development during this critical period. Choice A is incorrect as rubella does not typically cause reproductive and urinary defects. Choice C is incorrect because rubella does not usually result in spinal cord and skeletal defects. Choice D is incorrect as polydactyly and club feet are not typical manifestations of rubella infection during pregnancy.
A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.