Nokea
For each potential assessment finding, click to specity if the assessment finding Is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chilis
Correct Answer:
Rationale:
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A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule calculates the estimated date of delivery by adding 7 days to the first day of the last menstrual period, then subtracting 3 months, and finally adding 1 year. In this case, August 10 + 7 days = August 17. Subtracting 3 months gives us May 17, which is the estimated date of delivery. Choice A (May 13) is too early as it doesn't account for the full gestational period. Choice C (May 3) is also too early, and choice D (May 20) is too late based on the calculation.
Which of the following is a potential complication of a vacuum-assisted delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Neonatal cephalohematoma
- D. All of the above
Correct Answer: D
Rationale: Vacuum-assisted delivery can lead to fetal distress, maternal hemorrhage, and neonatal cephalohematoma.
A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?
- A. Evaluate uterine tone.
- B. Loosely wrap the cord with petroleum gauze.
- C. Apply fundal pressure.
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Placing the client in the Trendelenburg position helps reduce pressure on the prolapsed cord, preventing fetal distress. Other actions like applying fundal pressure or wrapping the cord are not appropriate.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: Epigastric pain in a pregnant client can be a sign of preeclampsia or HELLP syndrome, both of which are serious conditions that require immediate medical attention.
Which of the following is a potential complication of gestational diabetes?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Polyhydramnios
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Polyhydramnios. Gestational diabetes can lead to increased fetal growth and higher amniotic fluid levels, causing polyhydramnios. This can lead to complications during delivery.
Incorrect choices:
A: Hyperglycemia is a symptom of gestational diabetes, not a complication.
B: Hypoglycemia is not a common complication of gestational diabetes.
D: Hypertension is not directly linked to gestational diabetes complications.