Nokea
The nurse is assessing pregnant clients. During which time frames should the nurse expect clients to report frequent urination throughout the night? Select all that apply.
- A. Before the first missed menstrual period
- B. During the first trimester
- C. During the second trimester
- D. During the third trimester
- E. One week following delivery
Correct Answer: B,D
Rationale: Urinary frequency is most likely to occur in the first and third trimesters. First-trimester urinary frequency occurs as the uterus enlarges in the pelvis and begins to put pressure on the bladder. In the third trimester, urinary frequency returns due to the increased size of the fetus and uterus placing pressure on the bladder. Women do not typically experience urinary changes before the first missed menstrual period. During the second trimester, the uterus moves into the abdominal cavity, putting less pressure on the bladder. Nocturnal frequency occurring a week after delivery may be a sign of a UTI.
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The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.
- A. “Return for a blood transfusion if bleeding continues to be dark red.”
- B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
- C. “I can make a referral to a pregnancy loss support group if you like.”
- D. “You need to use contraceptives to avoid getting pregnant for one year.”
- E. “Someone should remain with you at home for the first 12 to 24 hours.”
Correct Answer: C,E
Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? Select all that apply.
- A. “You should change your peripad at least twice each day.”
- B. “Once home, use a warm sitz bath to sooth your perineum.”
- C. “Keep your perineum warm and dry until stitches are removed.”
- D. “Use your peri-bottle to apply water to the perineum after each void.”
- E. “Wash your perineum with mild soap at least once each 24 hours.”
- F. “Check your perineum for foul odor or increased redness, heat, or pain.”
Correct Answer: B,D,E,F
Rationale: The peripad should be changed more frequently to reduce the risk of infection. Lochia amount should never exceed a moderate amount (less than a 6-inch stain on a perineal pad). A warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce the incidence of infection. Perineal lacerations are repaired with sutures that dissolve. Clients do not need to have perineal sutures removed. Cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection. Washing with mild soap and rinsing with water each 24 hours reduces the risk of infection. Teaching the client to watch for signs and symptoms of infection is important and allows the client to be an active participant in her care.
Which assessment finding best represents a positive sign of pregnancy?
- A. Palpable fetal outline
- B. Blotchy tan facial skin
- C. Positive pregnancy test
- D. Fetal heartbeat
Correct Answer: D
Rationale: A fetal heartbeat, detected by Doppler or ultrasound, is a positive sign of pregnancy, as it directly confirms the presence of a living fetus.
Which laboratory test should the nurse monitor for a client with preeclampsia?
- A. Platelet count
- B. Blood glucose
- C. Cholesterol levels
- D. Thyroid function
Correct Answer: A
Rationale: Monitoring platelet count is critical in preeclampsia, as low platelets may indicate severe disease or HELLP syndrome.
Which sign of labor should the nurse teach the client to report immediately?
- A. Mild, irregular contractions
- B. Increased fetal movement
- C. Rupture of membranes
- D. Occasional backache
Correct Answer: C
Rationale: Rupture of membranes (water breaking) requires immediate reporting, as it may indicate the onset of labor or risk of infection.