Nokea
The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/—1 and that the fetal HR is 148. What priority information should the nurse collect before proceeding?
- A. Time and amount of last meal
- B. Number of weeks’ gestation
- C. Who is attending the delivery
- D. History of previous illnesses
Correct Answer: B
Rationale: Knowing the weeks of gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. If she is full term, the labor process could continue. The time and amount of last meal is important to know, but number of weeks’ gestation is more important. This client is dilated at 4 cm and in active labor. Who will attend the delivery should be identified during admission to the labor unit, but it is not the most important when being evaluated in triage. History of previous illnesses should be collected during admission to the labor unit, but it is not the most important when being evaluated in triage.
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In the primigravid client, when is fetal movement typically felt for the first time?
- A. Between 10 and 14 weeks' gestation
- B. Between 16 and 20 weeks' gestation
- C. Between 22 and 26 weeks' gestation
- D. Between 28 and 32 weeks' gestation
Correct Answer: B
Rationale: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
The nurse explains that true labor contractions are characterized by which feature?
- A. Irregular timing
- B. Increasing intensity and frequency
- C. Relief with walking
- D. Occurrence only at night
Correct Answer: B
Rationale: True labor contractions increase in intensity and frequency, distinguishing them from false labor.
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post—cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL
- B. 1.0 mL
- C. 2.0 mL
- D. 4.0 mL
Correct Answer: 0.5 mL
Rationale: (2 mg / 4 mg) x 1 mL = 0.5 mL. The nurse should administer 0.5 mL hydromorphone hydrochloride (Dilaudid).
The pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client’s chart notation to most accurately describe the client’s condition?
- A. Ectopic pregnancy
- B. Complete abortion
- C. Imminent abortion
- D. Incomplete abortion
Correct Answer: C
Rationale: In imminent abortion, the client’s bleeding and cramping increase and the cervix is open, which indicates that abortion is imminent or inevitable. In ectopic pregnancy, the pregnancy is outside of the uterus, and intervention is indicated to resolve the pregnancy. A complete abortion indicates that the contents of the pregnancy have been passed. In an incomplete abortion, a portion of the pregnancy has been expelled, and a portion remains in the uterus.
The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for which problems? Select all that apply.
- A. Susceptibility to infection
- B. Easily fatigued
- C. Increased risk for preeclampsia
- D. Increased risk of diabetes
- E. Congenital defects
Correct Answer: A,B,C
Rationale: Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. Iron-deficiency anemia is not associated with an increased risk of diabetes. Iron-deficiency anemia is not associated with an increased risk of congenital defects.