Nokea
The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
- A. Falling beta human chorionic gonadotropin (BHCG) measurement
- B. Low progesterone measurement
- C. Ultrasound showing a lack of fetal cardiac activity
- D. Ultrasound determining crown-rump length
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.
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The nurse is caring for the client who is Rh negative at 13 weeks’ gestation. The client is having cramping and has moderate vaginal bleeding. Which HCP order should the nurse question?
- A. Administer Rho(D) immune globulin (RhoGAM).
- B. Obtain a beta human chorionic gonadotropin level (BHCG).
- C. Schedule for an immediate ultrasound.
- D. Place on continuous external fetal monitoring.
Correct Answer: B
Rationale: Obtaining the BHCG level is not indicated at 13 weeks’ gestation. BHCG levels are followed in early pregnancy before a fetal heartbeat can be confirmed. RhoGAM is indicated for any pregnant client with bleeding who is Rh negative. An ultrasound can identify the cause of bleeding and confirm fetal viability. Continuous external fetal monitoring can be used to confirm a fetal heartbeat, fetal viability, and fetal risk.
The nurse educates the breastfeeding client diagnosed with mastitis. The nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements? Select all that apply.
- A. “Incorrect latch of my baby can lead to mastitis.”
- B. “I should perform hand hygiene before I breastfeed.”
- C. “I should rinse my baby’s mouth before I let her latch.”
- D. “A tight underwire bra has support that prevents mastitis.”
- E. “I should allow my nipples to air-dry after breastfeeding.”
Correct Answer: A,B,E
Rationale: Incorrect latch can cause nipple tissue to blister, crack, and bleed. These breaks in the tissue may serve as an entry point for pathogens. Hand hygiene prior to breastfeeding reduces the number of pathogens available for invasion. While the infant’s nose and throat are sources of pathogenic organisms that might cause mastitis, washing the infant’s mouth would be difficult and would not provide adequate protection for the mother. Wearing a tight bra, especially with an underwire, may restrict milk ducts, providing milk stasis and a medium for pathogenic growth. Allowing breasts to air-dry helps to reduce skin breakdown that might be caused by a moist, wet environment.
The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?
- A. Male health care providers should enter the room after receiving permission from her husband.
- B. The client may prefer to eat only “hot” foods and to drink only special tea and warm water.
- C. Fathers, rather than female relatives, are usually present to provide support during the labor.
- D. She will be more likely to moan, scream, or cry out in pain during each labor contraction.
Correct Answer: A
Rationale: Some Muslim women are not comfortable with male HCPs and may prefer to have their husband in the room if a male is involved in care. Eating “hot” foods and drinking special tea and warm water are preferences of Hmong women from Laos and not those of Muslim women. The Muslim client may choose to have her husband, a male relative, or a female friend or relative provide support during childbirth, rather than her father. Muslim women are more likely to be silent and stoic during labor contractions, and not cry out in pain.
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
- A. Inspect the client’s abdomen.
- B. Palpate the client’s abdomen.
- C. Perform a vaginal examination.
- D. Perform transabdominal ultrasound.
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.
The postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, “My breasts seem to be growing, and my bra no longer fits.” Which statement should be the basis for the nurse’s response to the client’s concern?
- A. Rapid enlargement of breasts usually is a symptom of infection.
- B. Increasing breast tissue may be a sign of postpartum fluid retention.
- C. Thrombi may form in veins of the breast and cause increased breast size.
- D. Breast tissue increases in the early postpartum period as milk forms.
Correct Answer: D
Rationale: Infection in the breast tissue results in flulike symptoms and redness and tenderness of the breast. It is usually unilateral and does not cause bilateral breast enlargement. Fluid is not retained during the postpartum period; rather, clients experience diuresis of the excess fluid volume accumulated during pregnancy. Fullness in both breasts would not be the result of thrombi formation. Symptoms of thrombi include redness, pain, and increased skin temperature over the thrombi. Breast tissue increases as breast milk forms, so a bra that was adequate during pregnancy may no longer be adequate by the second or third postpartum day.