Nokea
The nurse identifies which factor as increasing the risk of gestational hypertension?
- A. Low body mass index
- B. Family history of hypertension
- C. First pregnancy at age 20
- D. Vegetarian diet
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.
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The nurse prepares the client for which pain management option during labor?
- A. Epidural anesthesia
- B. Hot baths during active labor
- C. Over-the-counter pain relievers
- D. No pain relief options
Correct Answer: A
Rationale: Epidural anesthesia is a common and effective pain management option during labor, tailored to the client's needs.
How many factors in this scenario place the client at risk for nutritional deficiencies and the need for dietary guidance and counseling?
- A. Three
- B. Four
- C. Five
- D. Six
Correct Answer: C
Rationale: Five risk factors: adolescence, skipping meals, fast food diet, alcohol consumption, and weight gain concerns increase nutritional deficiency risk.
The nurse monitors which vital sign closely in a client with gestational diabetes?
- A. Blood pressure
- B. Respiratory rate
- C. Pulse rate
- D. Temperature
Correct Answer: A
Rationale: Blood pressure monitoring is crucial in gestational diabetes, as it increases the risk of preeclampsia.
The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
- A. Two finger-breadths above the symphysis pubis
- B. Halfway between the symphysis pubis and the umbilicus
- C. At the level of the umbilicus
- D. Two finger-breadths above the umbilicus
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
- A. “A decreased sensation of bladder filling is normal after childbirth.”
- B. “The oxytocin you received in labor makes it difficult to feel voiding.”
- C. “You probably didn’t empty completely. I will need to scan your bladder.”
- D. “Your bladder capacity is large; you likely won’t void again for 6—8 hours.”
Correct Answer: A
Rationale: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn’t completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.