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The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
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The nurse is caring for a patient who is receiving magnesium sulfate for pre-eclampsia. Which assessments will be of the highest priority?
- A. Assessing lung sounds
- B. Assessing blood sugar level
- C. Encouraging fluid intake
- D. Assessing for pitting edema
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate can cause respiratory depression, necessitating close monitoring of lung sounds to detect any signs of respiratory distress. Assessing lung sounds is crucial for early detection and intervention. Blood sugar level (B) monitoring is not directly related to magnesium sulfate therapy. Encouraging fluid intake (C) may be important, but not as critical as assessing lung sounds. Assessing for pitting edema (D) is important for overall assessment but not the highest priority in this scenario.
A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
- A. Blood pressure of 155/95
- B. Urinary output is greater than 30 mL/hr
- C. Deep tendon reflexes +2
- D. Client complains of blurred vision
Correct Answer: A
Rationale: The correct answer is A (Blood pressure of 155/95) because an elevated blood pressure indicates worsening pre-eclampsia. In pre-eclampsia, high blood pressure is a key indicator of worsening condition, potentially leading to eclampsia or seizures if left untreated. Choices B (Urinary output is greater than 30 mL/hr), C (Deep tendon reflexes +2), and D (Client complains of blurred vision) are not indicative of worsening pre-eclampsia. Increased urinary output, normal deep tendon reflexes, and blurred vision are common symptoms in pre-eclampsia, but they do not necessarily signify worsening of the condition.
The nurse is caring for a client with severe hyperemesis gravidarum. She is 10 weeks gestation and has a 10% weight loss. The client is being admitted for fluid and electrolyte replacement. The nurse is aware it is important to check which deficiency that puts the client at risk for Wernicke’s encephalopathy?
- A. Folic acid
- B. Vitamin D
- C. Thiamine
- D. Glucose
Correct Answer: C
Rationale: The correct answer is C: Thiamine. In severe hyperemesis gravidarum, excessive vomiting can lead to thiamine deficiency, increasing the risk of Wernicke's encephalopathy, a neurological disorder. Thiamine is essential for the brain's energy metabolism. Without adequate thiamine, neurological symptoms such as confusion, memory issues, and ataxia can arise. Folic acid (choice A) is important for neural tube development but not directly related to Wernicke's encephalopathy. Vitamin D (choice B) deficiency can lead to various issues but is not associated with Wernicke's encephalopathy. Glucose (choice D) is a source of energy but does not directly influence thiamine deficiency and Wernicke's encephalopathy.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: The correct answer is A: Changing cat litter. Chorioamnionitis is an infection of the amniotic fluid and membranes. Changing cat litter exposes the woman to toxoplasmosis, a risk factor for chorioamnionitis. Choices B, C, and D are incorrect. Vaginal exams during labor can introduce bacteria but are not a direct risk factor. Gestational diabetes is unrelated, and preterm premature rupture of membranes can increase infection risk but is not a direct cause like exposure to toxoplasmosis.
A nurse is caring for a client who is G1P0 and 36 weeks gestation who has been diagnosed with severe pre-eclampsia. Her blood pressure is 165/110. The physician has ordered hydralazine. The nurse knows she should do which of the following when administering this medication?
- A. Position the client supine with the head of the bed elevated 30 degrees.
- B. Get baseline blood pressure and pulse and monitor frequently during administration.
- C. Administer medication every 5 minutes until blood pressure is stabilized.
- D. Inform the client that this may cause a positive direct Coombs test result.
Correct Answer: B
Rationale: The correct answer is B. The nurse should get baseline blood pressure and pulse and monitor frequently during administration to assess the effectiveness and safety of the medication. This is crucial in managing severe pre-eclampsia.
Choice A is incorrect because the client should be positioned on her left side to prevent vena cava compression, not supine with the head of the bed elevated.
Choice C is incorrect because administering medication every 5 minutes without proper monitoring can lead to adverse effects like hypotension.
Choice D is incorrect because hydralazine does not cause a positive direct Coombs test result. It is important for the nurse to provide accurate information to the client.