Nokea
The experienced nurse instructs the new nurse that a vaginal examination should not be performed on the newly admitted client with possible grade 3 abruptio placentae. Which illustration shows the new nurse’s thinking about the uterus of the client with the grade 3 abruptio placentae?
- A. Illustration 1
- B. Illustration 2
- C. Illustration 3
- D. Illustration 4
Correct Answer: D
Rationale: Illustration 4 shows severe grade 3 abruptio placentae. More than 50% of the placenta separates with concealed hemorrhage. Illustration 1 shows complete placenta previa and not abruptio placentae. Illustration 2 shows partial placenta previa and not abruptio placentae. Illustration 3 shows mild grade 1 abruptio placentae. Less than 15% of the placenta separates with concealed hemorrhage.
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Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.
The nurse educates the breastfeeding client diagnosed with mastitis. The nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements? Select all that apply.
- A. “Incorrect latch of my baby can lead to mastitis.”
- B. “I should perform hand hygiene before I breastfeed.”
- C. “I should rinse my baby’s mouth before I let her latch.”
- D. “A tight underwire bra has support that prevents mastitis.”
- E. “I should allow my nipples to air-dry after breastfeeding.”
Correct Answer: A,B,E
Rationale: Incorrect latch can cause nipple tissue to blister, crack, and bleed. These breaks in the tissue may serve as an entry point for pathogens. Hand hygiene prior to breastfeeding reduces the number of pathogens available for invasion. While the infant’s nose and throat are sources of pathogenic organisms that might cause mastitis, washing the infant’s mouth would be difficult and would not provide adequate protection for the mother. Wearing a tight bra, especially with an underwire, may restrict milk ducts, providing milk stasis and a medium for pathogenic growth. Allowing breasts to air-dry helps to reduce skin breakdown that might be caused by a moist, wet environment.
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
- A. Encourage the client to push.
- B. Notify the obstetrician or midwife.
- C. Help the client to the bathroom.
- D. Complete another vaginal exam.
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
The nurse is counseling the client who is pregnant. The nurse should teach that which assessment finding requires follow-up with the HCP?
- A. Dependent edema
- B. Edema in the hands
- C. Generalized edema
- D. Edema occurring every evening
Correct Answer: C
Rationale: The nurse needs to teach the client that generalized edema is a sign of preeclampsia and requires follow-up by an HCP for further evaluation. Dependent edema is typical during pregnancy, resulting from relaxation of the blood vessels in the legs and decreased venous blood return. Edema in the hands is typical during pregnancy, particularly when a high-sodium diet is consumed. Edema that occurs every evening is a normal finding associated with decreased venous return and pelvic congestion from daily activity.
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
- A. Weekly for the remainder of the pregnancy
- B. Every 2 weeks for the remainder of the pregnancy
- C. Every 2 weeks up to 36 weeks, then weekly for the last month
- D. Weekly up to 36 weeks, then twice weekly for the last month
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.