Nokea
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 showing protein of 3+ indicates significant proteinuria, a sign of preeclampsia in pregnancy. Preeclampsia can lead to serious complications for both the mother and the baby, such as eclampsia and fetal growth restriction. The nurse should further assess the client's blood pressure, perform additional tests for preeclampsia, and closely monitor the client's condition.
Choice A: Hemoglobin and hematocrit levels are within normal range for pregnancy and do not require immediate intervention.
Choice B: Blood pressure of 130/80 is slightly elevated but not concerning at this gestational age. Close monitoring is recommended.
Choice C: Slight pedal swelling is common in pregnancy due to fluid retention and usually does not indicate a serious issue.
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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: Assessing lung sounds. This is of highest priority because magnesium sulfate can lead to respiratory depression. Assessing lung sounds helps monitor for signs of respiratory distress, such as decreased breath sounds or crackles. Assessing blood sugar level (B) is important but not as urgent as respiratory status. Encouraging fluid intake (C) is important for hydration but not as critical as respiratory assessment. Assessing for pitting edema (D) is relevant for monitoring fluid retention but not as immediate as assessing lung sounds for respiratory compromise.
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 (above 6.5-7%) signifies uncontrolled diabetes.
4. Choice C is correct as it aligns with the interpretation of HbA1c.
Summary:
- Choice A is incorrect as 10% is not a normal HbA1c value.
- Choice B is incorrect as a low value would indicate good control.
- Choice D is incorrect as HbA1c is a key marker for diabetes management.
The doctor suspects that the client is in preterm labor. Which symptom is consistent with this diagnosis?
- A. Severe pain in the lower quadrant
- B. Severe pain and hard abdomen to palpation
- C. Painless vaginal bleeding
- D. Abdominal cramping and lower back pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal cramping and lower back pain. This symptom is consistent with preterm labor as it indicates contractions and possible cervical changes. Severe pain in the lower quadrant (A) is more likely related to other conditions like ectopic pregnancy. Severe pain and hard abdomen to palpation (B) may suggest a more acute issue like placental abruption. Painless vaginal bleeding (C) is typically seen in conditions like placenta previa. Therefore, choice D is the most indicative of preterm labor based on the symptoms presented.
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 because administering antiretroviral drugs as ordered helps reduce the risk of vertical transmission of HIV from mother to baby during childbirth. This treatment is essential in managing the client's HIV status and ensuring the safety of the newborn.
Choice B is incorrect because using a labor ball does not directly address the HIV status of the client or the transmission risk to the newborn.
Choice C is incorrect as wearing gloves when handling the newborn does not replace the need for antiretroviral therapy to prevent transmission.
Choice D is incorrect because breastfeeding can transmit HIV from mother to baby, so it is not recommended for HIV-positive mothers to breastfeed.
The nurse is caring for a client with a suspected hydatidiform mole. Based on the diagnosis, what does the nurse anticipate? Select all that apply.
- A. Dark brown vaginal bleeding
- B. Strong fetal heart tones
- C. Fundal height larger than expected
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Strong fetal heart tones. In a hydatidiform mole, the pregnancy is abnormal and does not involve a fetus. Therefore, the absence of fetal heart tones is expected. Dark brown vaginal bleeding (A) is not specific to a hydatidiform mole. Fundal height larger than expected (C) and elevated blood pressure (D) are not typically associated with a hydatidiform mole.