Nokea
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings show potential prenatal complication?
- A. Periodic tingling of fingers
- B. Absence of clonus
- C. Leg cramps
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision is a potential prenatal complication during the third trimester of pregnancy and can be a sign of conditions such as preeclampsia or gestational diabetes. It is important for the nurse to further assess this finding and consult with the healthcare provider to ensure appropriate management and monitoring of the client's condition. Periodic tingling of fingers, absence of clonus, and leg cramps are common discomforts during pregnancy and do not typically indicate a prenatal complication.
You may also like to solve these questions
A newborn's birth was prolonged because the shoulders were very wide. The nurse performing the assessment would be particularly observant for a problem with the:
- A. Moro reflex
- B. Plantar reflex
- C. Babinski reflex
- D. Stepping reflex
Correct Answer: A
Rationale: The Moro reflex is a normal infantile reflex that is typically present at birth and disappears around 4-6 months of age. This reflex is triggered by a sudden loss of support or a loud noise, causing the infant to throw back the head and extend the arms in a gesture as if trying to grab something. In a situation where the newborn's birth was prolonged due to wide shoulders, there is a higher risk of injury to the brachial plexus (nerves that control arm movement) during delivery. Damage to the brachial plexus can result in weakness or paralysis of the affected arm, and this may impact the Moro reflex as it involves the arms' movement. Therefore, the nurse would be particularly observant for any abnormality or lack of response in the Moro reflex as it may indicate potential nerve injury related to the difficult birth.
A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hr ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation Which of the following findings indicates that it is safe for the nurse to continue the infusion? .
Correct Answer: A
Rationale: The client who experienced a cesarean birth 4 hours ago and is reporting pain should be seen first by the nurse. Pain assessment and management are crucial following a cesarean birth to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and affect the client's recovery process. Addressing the client's pain promptly is a priority to promote their comfort and facilitate their recovery.
After delivery it is determined there is a placental accreta, what intervention should the nurse anticipate?
- A. Hysterectomy
- B. IV antibiotic
- C. IV Pitocin
- D. 2L oxygen by mask
Correct Answer: A
Rationale: In the case of placental accreta, where the placenta is abnormally attached to the uterine wall, it can be very difficult to detach the placenta without significant bleeding. In severe cases, the safest intervention to prevent life-threatening hemorrhage is a hysterectomy, which involves the removal of the uterus. This is a serious surgical procedure that may be necessary to save the mother's life. Other interventions mentioned in the options (IV antibiotic, IV Pitocin, 2L oxygen by mask) may be part of the management plan but would not address the underlying issue of placental accreta like a hysterectomy would.
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning the woman9s care. The nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus due to the GDM. The nurse identifies that the fetus is at risk for which of the following? Congenital anomalies of the central nervous system Macrosomia Preterm birth Low birth weight Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:
- A. macrosomia.
- B. congenital anomalies of the central nervous system.
- C. preterm birth.
- D. low birth weight. A
Correct Answer: A
Rationale: Gestational diabetes mellitus (GDM) is a condition where high blood sugar levels develop during pregnancy in women who didn't have diabetes before pregnancy. One of the primary risks associated with GDM is fetal overgrowth, also known as macrosomia. This means the baby is larger than normal. Macrosomia can lead to complications during delivery, such as shoulder dystocia (when the baby's shoulders get stuck during delivery) and an increased risk of birth injuries for both the baby and the mother. It can also increase the likelihood of a cesarean section delivery. Therefore, preventing macrosomia is an important goal in managing GDM to ensure the safety and well-being of both the mother and the baby.
What statement by a client suggests the relationship may be in the 'honeymoon phase'?
- A. My partner said that he will never hurt me again.
- B. My partner drinks alcohol only on the weekends.
- C. My partner yells less than he used to.
- D. My partner has frequent bouts of insomnia.
Correct Answer: A
Rationale: Promises to stop abuse characterize the honeymoon phase.