Nokea
The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication?
- A. Abdominal enlargement
- B. Facial swelling
- C. Sudden weight gain
- D. Swelling of the feet and ankles
Correct Answer: C
Rationale: Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs, and hands follow weight gain.
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The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus. What can result from maternal rubella during pregnancy?
- A. Facial abnormalities
- B. Mental retardation
- C. Liver failure
- D. Limb deformities
Correct Answer: B
Rationale: Rubella can have devastating effects on the developing fetus. Some effects of rubella on the embryo or fetus include microcephaly, mental retardation, cardiac defects, cataracts, and deafness.
A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home health nurse make the first priority?
- A. Activity restriction
- B. Balanced nutrition
- C. Increased fluid intake to ensure adequate hydration
- D. Instruction about the effect of diuretics
Correct Answer: A
Rationale: Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and enhancing fetal oxygenation.
What situation would concern the nurse about the presence of Rh incompatibility?
- A. Rh-negative mother, Rh-positive fetus
- B. Rh-positive mother, Rh-negative fetus
- C. Rh-negative mother, Rh-negative fetus
- D. Rh-positive mother, Rh-positive fetus
Correct Answer: A
Rationale: Rh incompatibility can occur only if the mother is Rh negative and the fetus is Rh positive.
What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis?
- A. Frequency and urgency of urination
- B. Nausea and weight loss
- C. Burning sensation when voiding
- D. Tenderness in the flank area
Correct Answer: D
Rationale: Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills, flank pain or tenderness, nausea, and vomiting.
A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest?
- A. Toxoplasmosis
- B. Abruptio placentae
- C. Hydatidiform mole
- D. Diabetes mellitus
Correct Answer: D
Rationale: Large (macrosomic) infants over 9 pounds are linked to gestational diabetes.