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The doctor suspects that the client is in preterm labor. Which symptom is consistent with this diagnosis?
- A. Severe pain in the lower quadrant
- B. Severe pain and hard abdomen to palpation
- C. Painless vaginal bleeding
- D. Abdominal cramping and lower back pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal cramping and lower back pain. This symptom is consistent with preterm labor as it indicates contractions and possible cervical changes. Severe pain in the lower quadrant (A) is more likely related to other conditions like ectopic pregnancy. Severe pain and hard abdomen to palpation (B) may suggest a more acute issue like placental abruption. Painless vaginal bleeding (C) is typically seen in conditions like placenta previa. Therefore, choice D is the most indicative of preterm labor based on the symptoms presented.
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The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications.
Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: Rationale for correct answer (A): Changing cat litter exposes the woman to Toxoplasma gondii, a parasite associated with chorioamnionitis. It is a known risk factor as the infection can spread to the fetus.
Summary of incorrect choices:
B (Frequent vaginal examination during labor): This does not directly increase the risk of chorioamnionitis.
C (Gestational diabetes): While gestational diabetes can have other complications, it is not a direct risk factor for chorioamnionitis.
D (Preterm premature rupture of the membranes): While this can increase the risk of infection, it is not a specific risk factor for chorioamnionitis.
The nurse is assessing a client who has been diagnosed with gestational diabetes. Which should the nurse monitor closely because of her diagnosis?
- A. Edema
- B. Blood pressure, pulse, and respiration
- C. Urine for glucose and ketones
- D. Hemoglobin and hematocrit
Correct Answer: C
Rationale: The correct answer is C: Urine for glucose and ketones. In gestational diabetes, monitoring urine for glucose and ketones is crucial to assess blood sugar control and ketosis. Glucose in urine indicates hyperglycemia, and ketones indicate inadequate insulin and potential ketoacidosis. Monitoring edema (choice A) is not specific to gestational diabetes. Blood pressure, pulse, and respiration (choice B) are important but not specific to gestational diabetes. Monitoring hemoglobin and hematocrit (choice D) does not directly reflect blood sugar control in gestational diabetes.
A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
- A. Blood pressure of 155/95
- B. Urinary output is greater than 30 mL/hr
- C. Deep tendon reflexes +2
- D. Client complains of blurred vision
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A blood pressure of 155/95 indicates hypertension, a key feature of worsening pre-eclampsia. Hypertension in pre-eclampsia can lead to serious complications like eclampsia. High blood pressure can put the client at risk for seizures, stroke, and organ damage.
Incorrect choices:
B: Urinary output > 30 mL/hr is a positive sign, indicating adequate renal function, which is desirable in pre-eclampsia.
C: Deep tendon reflexes +2 are within normal limits and do not necessarily indicate worsening pre-eclampsia.
D: Blurred vision is a common symptom of pre-eclampsia but not a definitive sign of worsening condition.