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Client experiencing preterm labor, scheduled for amniocentesis
The client needs an amniocentesis to determine which of the following findings?
- A. Gender of the fetus
- B. Weeks of gestation
- C. Maturity of lungs
- D. Anatomic abnormalities
Correct Answer: C
Rationale: The correct answer is C: Maturity of lungs. Amniocentesis is a prenatal test that involves taking a sample of amniotic fluid to analyze fetal cells. The test can determine the maturity of the fetal lungs by measuring the level of surfactant, a substance produced by mature lungs. This information is crucial for assessing the fetus's lung function and determining the need for medical intervention if the lungs are not mature enough for birth.
Incorrect answers:
A: Gender of the fetus - Amniocentesis can determine the gender of the fetus, but this is not the primary purpose of the test.
B: Weeks of gestation - The gestational age can be estimated through ultrasound or other methods, not specifically through amniocentesis.
D: Anatomic abnormalities - While amniocentesis can detect some genetic abnormalities, it is not primarily used to detect anatomic abnormalities.
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Client at 34 weeks of gestation, suspected placenta previa
Which of the following actions should the nurse take?
- A. Perform a rectal exam.
- B. Apply an external fetal monitor.
- C. Complete a vaginal exam.
- D. Apply ice to the perineal area.
Correct Answer: B
Rationale: The correct answer is B: Apply an external fetal monitor. This action is crucial in monitoring the fetal heart rate and uterine contractions during labor, ensuring the well-being of both the mother and the baby. Performing a rectal exam (choice A) is not indicated in this context. Completing a vaginal exam (choice C) may be necessary but is not the immediate priority. Applying ice to the perineal area (choice D) is not relevant for fetal monitoring. Other choices are not provided.
Adult patient, physician orders Magnesium 4 gms loading dose to infuse over 30 minutes at 0500, then infuse a maintenance dose of 1 gram/hr, pharmacy sends 80 Gms in 1000 mL of LR
What would the nurse set the pump for the loading dose at 5 Am? Be sure to enter the number AND the unit of measurement (mL).
Correct Answer: 200 mL/hr
Rationale: The correct answer is 200 mL/hr. At 5 AM, the nurse would set the pump for the loading dose based on the prescribed rate per hour. By setting the pump at 200 mL/hr, the patient will receive the intended dose over the specified time. Choices A-G are incorrect as they do not align with the standard dosing calculations for the loading dose at 5 AM.
Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.
Client in second trimester, new diagnosis of gestational diabetes
Which statement by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will take my glyburide daily with breakfast.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I know I am at increased risk to develop type 2 diabetes.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week contradicts the goal of managing type 2 diabetes through regular physical activity. Exercise helps control blood sugar levels and improves insulin sensitivity. Limiting exercise can lead to poor diabetes management. Choice A shows understanding of carbohydrate control. Choice B indicates adherence to medication regimen. Choice D demonstrates awareness of diabetes risk.
Client in second trimester, new diagnosis of gestational diabetes
Which of the following statements by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of my daily caloric intake.
- B. I know I am at increased risk to develop type 2 diabetes.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I will take my glyburide daily with breakfast.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week goes against the goal of managing diabetes, which typically requires consistent physical activity. Regular exercise helps control blood sugar levels, improves insulin sensitivity, and promotes overall health. Choices A, B, and D demonstrate an understanding of diabetes management and medication adherence, indicating no need for further teaching in those areas.