Nokea
The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
- A. Administering antiretroviral drugs as ordered
- B. Assisting the woman on a labor ball to help with natural descent of the fetus
- C. Handling the newborn with gloves until it receives its first bath
- D. Encouraging the mother to breastfeed soon after delivery
Correct Answer: A
Rationale: The correct answer is A: Administering antiretroviral drugs as ordered. This is crucial in preventing vertical transmission of HIV from mother to child during childbirth. Antiretroviral therapy reduces the viral load in the mother's blood and bodily fluids, decreasing the risk of transmission. Choice B is beneficial for labor progress but not directly related to HIV care. Choice C is unnecessary as HIV is not transmitted through skin contact. Choice D is contraindicated as breastfeeding can transmit HIV from mother to child.
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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.
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
- A. Having high levels of hCG
- B. Having high blood pressure
- C. Being an adolescent
- D. Being underweight
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.
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 because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications.
Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.
A nurse is monitoring a client with type 2 diabetes mellitus. Her blood work reveals a glycosylated hemoglobin (HbA1c) of 10%. The nurse knows this blood work indicates which of the following?
- A. A normal value indicating that the client is managing blood glucose control well
- B. A low value indicating that the client is not managing blood glucose control very well
- C. A high value indicating that the client is not managing blood glucose control very well
- D. The value does not offer information regarding client management of her disease
Correct Answer: C
Rationale: Rationale:
1. HbA1c reflects average blood glucose levels over the past 2-3 months.
2. A value of 10% indicates poor blood glucose control.
3. High HbA1c (like 10%) signifies uncontrolled diabetes.
4. Choice C is correct due to the high HbA1c value.
Summary:
A: Incorrect as 10% is high, not normal.
B: Incorrect, as 10% is high, not low.
D: Incorrect, as HbA1c does offer information regarding diabetes management.
The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick reading of 3+ for protein indicates significant proteinuria, which can be a sign of preeclampsia in pregnancy. Preeclampsia poses serious risks to both the mother and the fetus, requiring immediate medical intervention.
Choice A: Hemoglobin and hematocrit levels within normal range for pregnancy.
Choice B: Blood pressure slightly elevated but not concerning at this gestational age.
Choice C: Slight pedal swelling is common in pregnancy and may not indicate a serious issue at this time.