Nokea
The nurse admits a client with preeclampsia to the high-risk prenatal unit. Which is the next nursing action after the vital signs have been obtained?
- A. Calling the primary health care provider
- B. Checking the client's reflexes
- C. Determining the client's blood type
- D. Establishing an intravenous (IV) line
Correct Answer: B
Rationale: The correct answer is B: Checking the client's reflexes. This is important in assessing for signs of worsening preeclampsia, such as hyperreflexia. It helps determine the severity of the condition and guides further interventions. Calling the primary health care provider (A) may be necessary but not the immediate next step. Determining the client's blood type (C) is important but not urgent in this situation. Establishing an IV line (D) is important for treatment but assessing reflexes takes priority in preeclampsia management.
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A patient at 25 weeks' gestation has just been diagnosed with gestational diabetes. What is the most important education for the nurse to provide the patient at this time?
- A. induction of labor
- B. nutrition
- C. potential fetal complications
- D. potential maternal complications
Correct Answer: B
Rationale: The correct answer is B: nutrition. At 25 weeks' gestation with gestational diabetes, nutrition education is crucial to manage blood sugar levels and prevent complications. Proper diet control can help regulate blood glucose levels, ensuring optimal fetal growth and reducing the risk of macrosomia. Educating the patient on a balanced diet, monitoring carbohydrate intake, and understanding the glycemic index are essential. Induction of labor (choice A) is not indicated at this stage and may lead to potential complications. While discussing potential fetal (choice C) and maternal (choice D) complications is important, addressing nutrition takes precedence as it directly impacts the health of both the mother and the fetus.
Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
- A. direct Coombs test of twin A.
- B. direct Coombs test of twin B.
- C. indirect Coombs test of the mother.
- D. transcutaneous bilirubin level for both twins.
Correct Answer: C
Rationale: The correct answer is C, indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A. If the test is positive, it indicates sensitization has occurred, making RhoGAM necessary to prevent hemolytic disease in future pregnancies. Direct Coombs tests of the twins (choices A and B) are not relevant in this scenario as they assess for antibodies already attached to the red blood cells. Transcutaneous bilirubin levels (choice D) are used to monitor jaundice, not Rh incompatibility.
What adverse fetal effect is associated with undernutrition?
- A. hyperglycemia
- B. impaired bone development
- C. cardiovascular disorders
- D. psychiatric disorders
Correct Answer: B
Rationale: The correct answer is B: impaired bone development. Undernutrition during pregnancy can lead to inadequate nutrient supply for fetal bone development. Calcium and other minerals are essential for bone growth. Hyperglycemia (A) is associated with maternal diabetes, not undernutrition. Cardiovascular disorders (C) are more commonly linked to maternal obesity. Psychiatric disorders (D) are not directly caused by undernutrition in the fetus. In summary, impaired bone development is the most direct adverse fetal effect of undernutrition.
In which situation would a dilation and curettage (D&C) be indicated?
- A. Complete abortion at 8 weeks
- B. Incomplete abortion at 16 weeks
- C. Threatened abortion at 6 weeks
- D. Incomplete abortion at 10 weeks
Correct Answer: D
Rationale: A dilation and curettage (D&C) is indicated for an incomplete abortion at 10 weeks because it involves dilating the cervix and removing remaining products of conception from the uterus to prevent infection or excessive bleeding. Incomplete abortion at 16 weeks (Choice B) would be too advanced for a D&C and may require a different procedure. A complete abortion at 8 weeks (Choice A) does not require a D&C as all products of conception have already been expelled. Threatened abortion at 6 weeks (Choice C) indicates a possible miscarriage, but a D&C is not necessary unless the miscarriage is confirmed and incomplete.
Which postpartum patient requires further assessment?
- A. G4 P4 who has had four saturated pads during the last 12 hours
- B. G1 P1 with Class II heart disease who complains of frequent coughing
- C. G2 P2 with gestational diabetes whose fasting blood sugar level is 100 mg/dL
- D. G3 P2 postcesarean patient who has active herpes lesions on the labia
Correct Answer: B
Rationale: The correct answer is B because a postpartum patient with Class II heart disease complaining of frequent coughing requires further assessment due to the risk of exacerbating heart failure. Coughing can increase cardiac workload, leading to potential complications. Choice A may indicate excessive postpartum bleeding, which would require immediate intervention. Choice C has a slightly elevated blood sugar level but is not immediately concerning. Choice D may require monitoring and possibly treatment for active herpes lesions, but it is not as urgent as assessing a patient with heart disease and coughing.