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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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.
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 nurse is counseling the client who has SLE. The client tells the nurse that she plans to become pregnant in the next year. Which response by the nurse is correct?
- A. “It is best to plan for your pregnancy when you have been in remission for 6 months.”
- B. “Having systemic lupus erythematosus will not impact your pregnancy in any way.”
- C. “Your chances of having an infant with congenital malformations are increased with SLE.”
- D. “You will need to be scheduled for a cesarean delivery to prevent disease transmission.”
Correct Answer: A
Rationale: Planning for pregnancy with SLE when in remission for 6 months is correct. Pregnancy planned during periods of inactive or stable disease often results in giving birth to a healthy full-term baby without increased risks of pregnancy complications. Exacerbations of SLE can occur during pregnancy and impact pregnancy outcomes. There is no risk of congenital malformations associated with maternal SLE. However, the risk for spontaneous abortion, preterm labor and birth, and neonatal death is increased. SLE is not a transmissible disease, and there is no reason for a cesarean delivery.
The nurse advises the client to avoid which medication during pregnancy?
- A. Acetaminophen
- B. Aspirin
- C. Prenatal vitamins
- D. Iron supplements
Correct Answer: B
Rationale: Aspirin is generally avoided in pregnancy due to risks of bleeding and fetal complications, unlike acetaminophen, which is safer.
Which fetal heart rate must the nurse report immediately to the physician?
- A. 100 beats/minute
- B. 120 beats/minute
- C. 140 beats/minute
- D. 160 beats/minute
Correct Answer: A
Rationale: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.