Nokea
The nurse evaluates the pregnant client with sickle cell disease during her second trimester. The nurse should identify which manifestation as being related to sickle cell disease and not the pregnancy?
- A. Hand and lower extremities edema
- B. Elevated serum blood glucose level
- C. Decreased oxygen saturation level
- D. Elevated blood pressure
Correct Answer: C
Rationale: Decreased oxygen saturation level is a clinical manifestation of sickle cell disease. Dehydration and anemia during pregnancy can result in vaso-occlusive crisis, which causes damage to RBCs and decreased oxygenation. The decrease in oxygenation manifests in decreased oxygen saturation levels. Edema is a normal finding related to pregnancy. A decrease in osmotic pressure causes a shift of body fluids into interstitial spaces, leading to edema. Elevated serum blood glucose levels after a meal help ensure that there is a sustained supply of glucose available for the fetus. Sustained elevation may be associated with pregnancy-related diabetes, not sickle cell disease. Elevated BP is associated with essential hypertension or preeclampsia.
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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.
The pregnant client tells the nurse that she smokes two packs per day (PPD) of cigarettes, has smoked in other pregnancies, and has never had any problems. What is the nurse’s best response?
- A. “I’m glad that your other pregnancies went well. Smoking can cause both maternal and fetal problems, and it is best if you could quit smoking.”
- B. “You need to stop smoking for the baby’s sake. You could have a spontaneous abortion with this pregnancy if you continue to smoke.”
- C. “Smoking can lead to having a large baby, which can make delivery difficult. You may even need a cesarean section.”
- D. “Smoking less would eliminate the risk for your baby, and you would feel healthier during your pregnancy.”
Correct Answer: A
Rationale: The nurse is acknowledging that the client did not experience problems with her other pregnancies but is also informing the client that smoking can cause maternal and fetal problems during pregnancy. Telling the client to stop smoking for the baby’s sake is confrontational, making the client less likely to listen to the nurse’s teaching. Although spontaneous abortion is associated with tobacco use during pregnancy, the nurse is using a scare tactic rather than therapeutic communication. Smoking can lead to a fetus that is small for gestational age, not a large baby. Decreasing her smoking intake should be suggested; however, it does not eliminate the risk to the baby completely.
The 38-year-old pregnant client at 22 weeks’ gestation has just been told she has hydramnios after undergoing a sonogram for size greater than dates. The nurse should further assess for which conditions associated with hydramnios? Select all that apply.
- A. A congenital anomaly
- B. Gestational diabetes
- C. Chronic hypertension
- D. TORCH infections
- E. Preeclampsia
Correct Answer: A,B,D
Rationale: In cases of anencephaly, the fetus is thought to urinate excessively because of overstimulation of the cerebrospinal centers, resulting in hydramnios. The nurse should further assess for gestational diabetes. Hydramnios is thought to occur from excessive fetal urination due to fetal hyperglycemia. Infants with mothers infected with toxoplasmosis, rubella, CMV, or herpes simplex virus infections (TORCH) are more likely to have hydramnios due to the inflammatory response and fluid accumulation. Chronic hypertension is not associated with excess amniotic fluid. Preeclampsia is not associated with excess amniotic fluid.
Which item should the client include in her hospital bag?
- A. Comfortable loose clothing
- B. High-heeled shoes
- C. Heavy perfumes
- D. Large meals
Correct Answer: A
Rationale: Comfortable loose clothing is practical for labor and postpartum, ensuring ease and comfort.
The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for two days now. Which response by the nurse is correct?
- A. “You need to come to the clinic as soon as possible.”
- B. “You’ll need an antibiotic; which pharmacy do you use?”
- C. “Take your temperature and let me know if it is elevated.”
- D. “A creamy white discharge 10 days postpartum is normal.”
Correct Answer: D
Rationale: There is no need to be seen in the clinic; vaginal discharge that turns creamy white 10 days postpartum is normal. The client does not have an infection, and no antibiotic is necessary. There is no reason to take her temperature when the discharge is normal. Creamy white discharge 10 to 21 days postpartum is normal. Her lochia changed color on her 10th postpartum day.