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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Which dietary recommendation supports postpartum recovery?
- A. High-protein, balanced diet
- B. Low-calorie, restrictive diet
- C. High-sugar snacks
- D. Caffeine-only beverages
Correct Answer: A
Rationale: A high-protein, balanced diet supports tissue repair and energy needs during postpartum recovery.
The nurse is reviewing the laboratory report from the first prenatal visit of the pregnant client. Which laboratory result should the nurse most definitely discuss with the HCP?
- A. Hemoglobin 11 g/dL; hematocrit 33%
- B. White blood cell (WBC) count: 7000/mm3
- C. Pap smear: human papilloma virus changes
- D. Urine pH: 7.4; specific gravity 1.015
Correct Answer: C
Rationale: A Pap smear with HPV changes reflects an abnormal result. HPV changes are a risk factor for cervical cancer. The nurse should discuss the result with the HCP because it requires further assessment and follow-up. A normal Hgb is 12—15 g/dL; nutritional counseling should be initiated when the Hgb is less than 12 g/dL. An Hct of 33% is also low (normal Hct value = 38% to 47%; this decreases by 4% to 7% in pregnancy), but increasing the Hgb with iron-rich foods should also raise the Hct. A WBC count of 7000/mm3 is within the normal range of 5000 to 12,000/mm3. A urine pH of 7.4 is within the normal range of 4.6 to 8.0; the specific gravity is within the normal range of 1.010 to 1.025.
Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?
- A. An intrauterine device (IUD)
- B. Depot-medroxyprogesterone acetate injections
- C. A female condom with nonoxynol-9
- D. A diaphragm
Correct Answer: C
Rationale: IUDs offer no protection against STIs. They are recommended for women who are in a stable, mutually monogamous relationship. Depot-medroxyprogesterone acetate (Depo-Provera) is a long-acting progestin that is highly effective for birth control. A single injection will provide contraception for 3 months but does not offer protection against STIs. A female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter. A diaphragm offers no protection against STIs.
Which expected outcome should the nurse include based on the client's eating habits?
- A. The client will eat three balanced meals and two snacks daily while pregnant.
- B. The client will gain a total of 50 pounds during the pregnancy.
- C. The client will take two prenatal vitamins daily.
- D. The client will report eating about 2,000 calories per day.
Correct Answer: A
Rationale: Eating three balanced meals and two snacks daily addresses the client's poor eating habits and supports nutritional needs.
When planning for this test, which one of the following items should the nurse have available?
- A. The emergency crash cart
- B. A cardiac monitor
- C. An ultrasound machine
- D. A fetal monitor
Correct Answer: D
Rationale: A nonstress test requires a fetal monitor to assess fetal heart rate and movement, ensuring fetal well-being.