Nokea
The nurse assesses the 34-week pregnant client (G2P1). Place the assessment findings in the sequence that they should be addressed by the nurse from the most significant to the least significant.
- A. Pedal edema at +3
- B. BP 144/94 mm Hg
- C. Positive group beta streptococcus vaginal culture
- D. Fundal height increase of 4.5 cm in 1 week
Correct Answer: B,D,A,C
Rationale: BP 144/94 mm Hg warrants immediate evaluation. It could indicate preeclampsia, a condition that can progress to serious complications. Fundal height increase of 4.5 cm in 1 week is abnormal and requires further follow-up. Normal fundal height increase is 1 to 2 cm per week. An increase in fundal size can be related to gestational diabetes, large-for-gestational-age fetus, fetal anomalies, or polyhydramnios. Pedal edema at +3 may be a normal physiological process if it is an isolated finding. Pedal edema warrants further assessment because it can be a symptom of preeclampsia. Positive group beta streptococcus vaginal culture warrants antibiotic treatment in labor but does not warrant intervention during the pregnancy.
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The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? Select all that apply.
- A. Oral temperature of 102.2°F (39°C)
- B. Telangiectasis on the neck and chest
- C. Mild abdominal tenderness with palpation
- D. Lochial discharge that is foul smelling
- E. White blood cell count of 16,500 cells/mm3
Correct Answer: A,D
Rationale: A temperature of 100.4°F (38°C) or higher after 24 hours postpartum is associated with a puerperal infection. Telangiectasis is red, slightly raised vascular “spiders” that may appear during pregnancy over the neck, thorax, face, or arms and remain or fade during the postpartum period. It is not indicative of an infection. Slight abdominal tenderness with palpation is a normal postpartum finding. Malodorous lochia is a common sign of a puerperal infection. A WBC count of 16,500 is normal for the postpartum client; labor produces a mild pro-inflammatory state.
The nurse practitioner informs the new nurse that the laboring client’s monitor is showing prolonged decelerations. Which interpretation by the new nurse is correct?
- A. The monitor pattern is U or V shaped, with a decrease in FHR to less than 70 beats/minute (bpm), lasting more than 60 seconds.
- B. The FHR shows an episodic or periodic acceleration that lasts 2 minutes or more but less than 10 minutes in duration.
- C. There is an FHR decrease of 15 bpm or more below baseline occurring for at least 2 but not more than 10 minutes.
- D. The mother’s heart rate is exhibiting intermittent or transient deviations or changes from the baseline heart rate.
Correct Answer: C
Rationale: A prolonged deceleration occurs when the FHR decreases 15 bpm or more below baseline for at least 2 but not more than 10 minutes. The prolonged deceleration may resolve spontaneously or with the aid of interventions. A U- or V-shaped pattern with abrupt decrease in the FHR to less than 70 bpm, lasting more than 60 seconds, describes variable (not prolonged) deceleration typically associated with cord compression. Any episodic or periodic acceleration of FHR that lasts 2 minutes or more but less than 10 minutes in duration describes prolonged acceleration, not deceleration. The fetal heart monitor is monitoring the FHR and not the mother’s heart rate.
The nurse advises the client with constipation to increase intake of which food?
- A. High-fiber fruits and vegetables
- B. White rice
- C. Processed meats
- D. Sugary desserts
Correct Answer: A
Rationale: High-fiber fruits and vegetables promote bowel regularity, relieving constipation safely during pregnancy.
Which client is at highest risk for ectopic pregnancy?
- A. A client with a history of pelvic inflammatory disease
- B. A client with a normal ultrasound
- C. A client with regular menstrual cycles
- D. A client taking prenatal vitamins
Correct Answer: A
Rationale: Pelvic inflammatory disease increases the risk of ectopic pregnancy by causing tubal scarring, which can impede embryo passage.
Which statement by the client indicates a need for further psychosocial support?
- A. I feel ready to bond with my baby.
- B. I am excited about becoming a mother.
- C. I feel worthless and overwhelmed daily.
- D. I have a great support system at home.
Correct Answer: C
Rationale: Feeling worthless and overwhelmed daily suggests potential depression, indicating a need for additional psychosocial support.