Nokea
The 22-year-old client tells the clinic nurse that her last menstrual period was 3 months ago, which began on November 21. She has a positive urine pregnancy test. Using Naegele’s rule, which date should the nurse calculate to be the client’s estimated date of confinement (EDC)?
- A. August 28
- B. January 28
- C. August 15
- D. January 15
Correct Answer: A
Rationale: Naegele’s rule is a common method to determine the EDC. To calculate the EDC, subtract 3 months and add 7 days. This makes the EDC August 28. An EDC of January 28 was calculated by adding 2 months and 7 days. An EDC of August 15 was calculated by subtracting 3 months and 6 days. An EDC of January 15 was calculated by adding 2 months and subtracting 6 days.
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The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last.
- A. The client who had a normal, spontaneous vaginal delivery 30 minutes ago.
- B. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant.
- C. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding.
- D. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control.
Correct Answer: A,D,C,B
Rationale: The client who had a normal, spontaneous vaginal delivery 30 minutes ago is priority. The first 2 hours after delivery is a time of transition, characterized by rapid changes in hemodynamic and physiological state for both the client and her newborn. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control should be assessed next. Although she is 8 hours postpartum and probably stable, she is receiving morphine, and her respiratory status should be monitored Drag and Droply. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding should be assessed next. Newborn infants should successfully breastfeed every 2—3 hours. Failing to breastfeed with adequate amount and frequency may lead to newborn complications such as excessive weight loss and jaundice. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant should be seen last; there is nothing indicating urgency.
To best enhance absorption of the iron supplement, which foods should the nurse recommend the client increase in her diet? Select all that apply.
- A. Oranges
- B. Potatoes
- C. Bananas
- D. Broccoli
- E. Whole milk
- F. Carrots
Correct Answer: A,D
Rationale: Oranges and broccoli are rich in vitamin C, which enhances iron absorption, unlike the other options.
The nurse is conducting a physical assessment of the pregnant client. Which physiological cervical changes associated with pregnancy should the nurse expect to find? Select all that apply.
- A. Formation of mucus plug
- B. Chadwick’s sign
- C. Presence of colostrum
- D. Goodell’s sign
- E. Cullen’s sign
Correct Answer: A,B,D
Rationale: Cervical changes associated with pregnancy include the formation of the mucus plug. Endocervical glands secrete a thick, tenacious mucus, which accumulates and thickens to form the mucus plug that seals the endocervical canal and prevents the ascent of bacteria or other substances into the uterus. This plug is expelled when cervical dilatation begins. Cervical changes associated with pregnancy include a bluish-purple discoloration of the cervix (Chadwick’s sign) from increased vascularization. Cervical changes associated with pregnancy include the softening of the cervix (Goodell’s sign) from increased vascularization and hypertrophy and engorgement of the vessels below the growing uterus. Colostrum does occur with pregnancy but is a physiological change associated with the breasts and not with a cervical change. Cullen’s sign is a bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. It can occur with a ruptured ectopic pregnancy or acute pancreatitis.
The nurse advises the client that this test is typically performed at what time during the pregnancy?
- A. Just after the pregnancy is confirmed
- B. Early in the second trimester
- C. In the transition phase of labor
- D. Just after the first fetal movements
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
- A. Administering hydralazine
- B. Maintaining the client on bedrest
- C. Preparing the client for a nonstress test
- D. Giving betamethasone
- E. Administering metronidazole
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.