Nokea
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?
- A. Cloudy in color
- B. Has a strong odor
- C. Meconium stained
- D. Has a pH of 7.1
Correct Answer: D
Rationale: The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material. Normal amniotic fluid should be clear. Cloudiness could indicate the presence of meconium or an intrauterine infection. Amniotic fluid should have no odor. Any odor may indicate the presence of infection. Amniotic fluid should be clear. Meconium stained could indicate fetal distress.
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The nurse instructs the client with hyperemesis gravidarum to avoid which trigger?
- A. Eating small, frequent meals
- B. Strong odors
- C. High-protein foods
- D. Adequate hydration
Correct Answer: B
Rationale: Strong odors can exacerbate nausea and vomiting in hyperemesis gravidarum, worsening symptoms.
The laboring client presents with ruptured membranes, frequent contractions, and bloody show. She reports a greenish discharge for 2 days. Place the nurse’s actions in the order that they should be completed.
- A. Perform a sterile vaginal exam
- B. Assess the client thoroughly
- C. Obtain fetal heart tones
- D. Notify the health care provider
Correct Answer: C,A,B,D
Rationale: Obtain FHT should be first. The client has ruptured membranes with greenish fluid, and the fetus could be experiencing nonreassuring fetal status. Perform a sterile vaginal exam to determine labor progression. Assess the client thoroughly. This needs to be completed prior to notifying the HCP with the information. Notify the HCP is last of the options. Assessment findings would need to be reported to the HCP. The client should then be moved into an inpatient room.
Which response by the nurse is most accurate?
- A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
- B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
- C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
- D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Correct Answer: C
Rationale: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.
The nurse identifies which sign as indicative of postpartum depression?
- A. Occasional mood swings
- B. Persistent feelings of hopelessness
- C. Excitement about motherhood
- D. Increased energy levels
Correct Answer: B
Rationale: Persistent feelings of hopelessness are a key indicator of postpartum depression, requiring intervention.
The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategies might the nurse suggest that the client use with her child? Select all that apply.
- A. Read books about bringing home a new baby.
- B. Think of unique names for the new baby.
- C. Help pack a bag for bringing the new baby home.
- D. Explain how pregnancy occurred, if asked.
- E. Help the child buy presents for the new baby.
Correct Answer: A,B,C,E
Rationale: Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience. Engaging the child in activities such as buying presents for the new baby helps the child to feel a part of the experience. Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.