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One week after her prenatal visit, a primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse complaining of a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client:
- A. "Take two acetaminophen tablets. They aren't as likely to upset your stomach."
- B. "I think the doctor should see you today. Can you come to the clinic this morning?"
- C. "You need to lie down and rest. Have you tried placing a cool compress over your head?"
- D. "I'll ask the doctor to call in a prescription for aspirin with codeine. What's your pharmacy's number?"
Correct Answer: B
Rationale: Continuous headache and nausea are signs of worsening preeclampsia requiring evaluation.
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The labor and delivery unit is short-staffed, and the charge nurse must prioritize assignments. Which client should the registered nurse personally assess first?
- A. A primigravida at 4 cm dilation requesting pain relief.
- B. A multigravida at 8 cm dilation with a history of rapid labors.
- C. A primigravida with stable vital signs post-epidural.
- D. A multigravida at 6 cm dilation with a reassuring fetal monitor.
Correct Answer: B
Rationale: A multigravida at 8 cm dilation with a history of rapid labors is at risk for precipitous delivery, requiring immediate RN assessment to prepare for birth. Other clients are less urgent, as they are earlier in labor or stable.
After being treated with heparin therapy for thrombophlebitis, a multiparous client who delivered 4 days ago is to be discharged on oral warfarin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching?
- A. I can take two aspirin if I get uterine cramps.
- B. Protamine sulfate should be available if I need it.
- C. I should use a soft toothbrush to brush my teeth.
- D. I can drink an occasional glass of wine if I desire.
Correct Answer: C
Rationale: Using a soft toothbrush minimizes bleeding risk, a key consideration with warfarin.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.
During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following?
- A. Congenital anomalies.
- B. Pulmonary hypertension.
- C. Meconium aspiration syndrome.
- D. Respiratory distress syndrome.
Correct Answer: D
Rationale: Cesarean delivery, especially without labor, increases the risk of respiratory distress syndrome due to retained lung fluid. Breech presentation may exacerbate this. Congenital anomalies, pulmonary hypertension, and meconium aspiration are less directly related.
While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal?
- A. Bradycardia.
- B. High-pitched cry.
- C. Sluggishness.
- D. Hypocalcemia.
Correct Answer: B
Rationale: A high-pitched cry is a common sign of cocaine withdrawal in neonates, indicating neurological irritability.