Nokea
The 38-year-old pregnant client at 22 weeks’ gestation has just been told she has hydramnios after undergoing a sonogram for size greater than dates. The nurse should further assess for which conditions associated with hydramnios? Select all that apply.
- A. A congenital anomaly
- B. Gestational diabetes
- C. Chronic hypertension
- D. TORCH infections
- E. Preeclampsia
Correct Answer: A,B,D
Rationale: In cases of anencephaly, the fetus is thought to urinate excessively because of overstimulation of the cerebrospinal centers, resulting in hydramnios. The nurse should further assess for gestational diabetes. Hydramnios is thought to occur from excessive fetal urination due to fetal hyperglycemia. Infants with mothers infected with toxoplasmosis, rubella, CMV, or herpes simplex virus infections (TORCH) are more likely to have hydramnios due to the inflammatory response and fluid accumulation. Chronic hypertension is not associated with excess amniotic fluid. Preeclampsia is not associated with excess amniotic fluid.
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When planning for this test, which one of the following items should the nurse have available?
- A. The emergency crash cart
- B. A cardiac monitor
- C. An ultrasound machine
- D. A fetal monitor
Correct Answer: D
Rationale: A nonstress test requires a fetal monitor to assess fetal heart rate and movement, ensuring fetal well-being.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
The nurse advises the client to avoid which medication during pregnancy?
- A. Acetaminophen
- B. Aspirin
- C. Prenatal vitamins
- D. Iron supplements
Correct Answer: B
Rationale: Aspirin is generally avoided in pregnancy due to risks of bleeding and fetal complications, unlike acetaminophen, which is safer.
The nurse evaluates the pregnant client with sickle cell disease during her second trimester. The nurse should identify which manifestation as being related to sickle cell disease and not the pregnancy?
- A. Hand and lower extremities edema
- B. Elevated serum blood glucose level
- C. Decreased oxygen saturation level
- D. Elevated blood pressure
Correct Answer: C
Rationale: Decreased oxygen saturation level is a clinical manifestation of sickle cell disease. Dehydration and anemia during pregnancy can result in vaso-occlusive crisis, which causes damage to RBCs and decreased oxygenation. The decrease in oxygenation manifests in decreased oxygen saturation levels. Edema is a normal finding related to pregnancy. A decrease in osmotic pressure causes a shift of body fluids into interstitial spaces, leading to edema. Elevated serum blood glucose levels after a meal help ensure that there is a sustained supply of glucose available for the fetus. Sustained elevation may be associated with pregnancy-related diabetes, not sickle cell disease. Elevated BP is associated with essential hypertension or preeclampsia.
Which item should the client include in her hospital bag?
- A. Comfortable loose clothing
- B. High-heeled shoes
- C. Heavy perfumes
- D. Large meals
Correct Answer: A
Rationale: Comfortable loose clothing is practical for labor and postpartum, ensuring ease and comfort.