Nokea
The blood of a pregnant client was initially assessed at 10 weeks’ gestation and reassessed at 38 weeks’ gestation.
- A. Rise in hematocrit from 34% to 38%.
- B. Rise in white blood cells from 5 000 cells/mm3 to 15 000 cells/mm3.
- C. Rise in potassium from 3.9 mEq/L to 5.2 mEq/L.
- D. Rise in sodium from 137 mEq/L to 150 mEq/L.
Correct Answer: B
Rationale: White blood cell count increases during pregnancy due to physiological stress and immune system changes. Hematocrit levels typically decrease due to plasma expansion, while potassium and sodium levels remain stable.
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A nurse is assessing the fetal heart rate of a laboring person. What is the most significant finding that would indicate fetal distress?
- A. variable decelerations
- B. late decelerations
- C. bradycardia
- D. accelerations
Correct Answer: C
Rationale: The correct answer is C, bradycardia. Bradycardia in the fetal heart rate is a significant finding indicating fetal distress because it signifies a heart rate below normal range, which can lead to inadequate oxygen supply to the fetus. Bradycardia can be a sign of fetal hypoxia, acidosis, or other serious conditions. Variable decelerations (choice A) are often caused by umbilical cord compression, late decelerations (choice B) are associated with uteroplacental insufficiency, and accelerations (choice D) are considered a reassuring sign of fetal well-being. Therefore, in the context of fetal distress, bradycardia is the most concerning finding.
A nurse is providing prenatal education to a pregnant patient. Which of the following statements indicates a need for further teaching about maternal weight gain during pregnancy?
- A. I should aim to gain about 25 to 35 pounds during my pregnancy.
- B. I should eat for two during pregnancy.
- C. I can exercise as long as I stay within my doctor's recommendations.
- D. Gaining too much weight during pregnancy can increase my risk of complications.
Correct Answer: B
Rationale: The correct answer is B because the statement "I should eat for two during pregnancy" is incorrect. The rationale is that during pregnancy, a woman does not need to eat for two individuals. Instead, she needs to consume additional calories to support the growth and development of the fetus. Eating for two could lead to excessive weight gain and potential complications. The other choices indicate correct understanding and knowledge about maternal weight gain during pregnancy. A suggests the recommended weight gain range, C acknowledges the importance of exercising within doctor's limits, and D highlights the risks of gaining too much weight during pregnancy.
The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination.
- A. Orthopneic.
- B. Lateral-recumbent.
- C. Sims'.
- D. Semi-Fowler’s.
Correct Answer: B
Rationale: The lateral-recumbent position reduces pressure on the inferior vena cava and is safer for pregnant women compared to other positions.
The nurse is caring for a pregnant patient who is experiencing frequent contractions. The patient asks the nurse if the contractions are normal. Which response by the nurse is most appropriate?
- A. Contractions are common at this stage and are usually harmless.
- B. Frequent contractions are always a sign of labor starting.
- C. Frequent contractions may be a sign of preterm labor, and further evaluation is needed.
- D. You should drink more water to stop the contractions from happening.
Correct Answer: C
Rationale: The correct answer is C: Frequent contractions may be a sign of preterm labor, and further evaluation is needed. This response is appropriate because frequent contractions in a pregnant patient can indicate preterm labor, which requires immediate medical attention to prevent potential complications for both the mother and the baby. It is crucial to evaluate the situation to determine the cause of the contractions and take appropriate actions.
Explanation for other choices:
A: Contractions are common at this stage and are usually harmless - This is inaccurate as frequent contractions, especially in a pregnant patient, should not be dismissed as harmless without proper evaluation.
B: Frequent contractions are always a sign of labor starting - This is incorrect because frequent contractions do not always indicate the onset of labor, especially in the case of preterm labor.
D: You should drink more water to stop the contractions from happening - This is not an appropriate response as hydration may not necessarily stop contractions, especially if they are due to pre
A nurse is assisting a postpartum person with breastfeeding. What is the best intervention to help relieve nipple pain?
- A. apply lanolin cream
- B. administer analgesics
- C. apply a warm compress
- D. apply cold compresses
Correct Answer: A
Rationale: The correct answer is A: apply lanolin cream. Lanolin cream helps to soothe and moisturize the nipples, reducing pain and promoting healing. It is safe for the baby and does not need to be removed before breastfeeding. Applying analgesics (B) is not recommended as they can be harmful to the baby. Warm compresses (C) may not provide the same level of relief for nipple pain as lanolin cream. Cold compresses (D) are not suitable for relieving nipple pain as they can further exacerbate discomfort. Therefore, applying lanolin cream is the best intervention for relieving nipple pain during breastfeeding.