Nokea
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Administer a pneumococcal immunization to the newborn within 4 hr. following birth.
- D. Bathe the newborn before initiating skin-to-skin contact
Correct Answer: C
Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.
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What tion in the FHR that is abrupt and appears to be does the nurse inform this group that they are at in the shape of a W. What is the most likely cause highest risk for? of this?
- A. Sexually transmitted diseases
- B. Compression of the fetal head
- C. Uterine cancer
- D. Compression of the umbilical cord
Correct Answer: D
Rationale: An abnormality in the FHR that is abrupt and appears to be in the shape of a "W" is often indicative of variable decelerations. Variable decelerations typically occur due to compression of the umbilical cord, leading to a temporary decrease in oxygen supply to the fetus. It is important for the nurse to inform this group that they are at the highest risk for compression of the umbilical cord as this can result in fetal distress and potentially lead to serious complications if not promptly addressed.
A couple who has stated that they are LGBTQIA+ during prior visits arrives at the clinic for prenatal care. What can the nurse say in the waiting area to help them feel welcome and safe?
- A. You can take this tablet to an area in the waiting room and check in. Then bring the tablet back to me when you are done.
- B. Are you pregnant? Your paperwork says your name is Tom.
- C. You can have a seat, and a person from the LGBTQIA+ office will come to assist you.
- D. Here is our paperwork. It doesn't have a box for your sex, but you can write it next to the gender box.
Correct Answer: A
Rationale: Providing a neutral and respectful approach helps create a welcoming environment for LGBTQIA+ patients.
A client at 12 weeks' gestation reports mild cramping and spotting. What is the nurse's priority intervention?
- A. Reassure the client that this is normal.
- B. Encourage the client to hydrate.
- C. Advise the client to avoid heavy lifting.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Spotting and cramping in early pregnancy could indicate a threatened miscarriage, requiring immediate evaluation.
The nurse is preparing a client for a nonstress test. What instruction is most appropriate?
- A. You need to fast for 12 hours before the test.
- B. You will be given medication to stimulate fetal movements.
- C. You will need to press a button each time you feel the baby move.
- D. You must lie flat on your back during the test.
Correct Answer: C
Rationale: The client presses a button during fetal movements, which are correlated with fetal heart rate changes.
The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
- A. Proteinuria.
- B. Blood pressure of 140/90 mmHg on two occasions.
- C. Edema of the hands and feet.
- D. Elevated blood glucose levels.
Correct Answer: B
Rationale: Gestational hypertension is diagnosed by consistent readings of 140/90 mmHg or higher without proteinuria.