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A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
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A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
- A. Varicella
- B. Human papillomavirus
- C. Diphtheria - acellular pertussis
- D. Inactivated influenza
Correct Answer: C,D
Rationale: The correct vaccinations for a pregnant client at 30 weeks gestation are C: Diphtheria-acellular pertussis (Tdap) and D: Inactivated influenza. Tdap is recommended during every pregnancy to protect the newborn from whooping cough, and influenza vaccine is safe and crucial to prevent flu-related complications. Varicella (A) and Human papillomavirus (B) vaccines are contraindicated during pregnancy due to potential risks to the fetus. Additionally, the incomplete choices (E, F, G) do not align with the recommended vaccinations during pregnancy.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception.
- A. You should use an oil-based vaginal lubricant when inserting your diaphragm
- B. You should store your diaphragm in sterile water after each use
- C. You should keep the diaphragm in place for at least 4 hours after intercourse
- D. You should have your provider refit you for a new diaphragm
Correct Answer: D
Rationale: The correct answer is D: You should have your provider refit you for a new diaphragm. After childbirth, the size and shape of the cervix and vaginal canal may change, affecting the fit of the diaphragm. It is essential to have a healthcare provider assess and refit the diaphragm to ensure proper contraception.
Incorrect answers:
A: Using oil-based vaginal lubricant can degrade latex diaphragms, leading to breakage.
B: Storing the diaphragm in sterile water can damage the latex material and increase the risk of infection.
C: Keeping the diaphragm in place for a specific time after intercourse is not necessary and can increase the risk of toxic shock syndrome.
E: Not applicable.
F: Not applicable.
G: Not applicable.
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Firm rigid abdomen
- B. Painless vaginal bleeding
- C. Uterine hypertonicity
- D. Persistent headache
Correct Answer: B
Rationale: The correct answer is B: Painless vaginal bleeding. In placenta previa, the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. This occurs due to separation of the placenta from the uterine wall. A firm rigid abdomen (A) is more indicative of abruptio placentae. Uterine hypertonicity (C) is seen in conditions like uterine rupture, not placenta previa. Persistent headache (D) is not typically associated with placenta previa.
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique.
- A. The plastibell will be removed 4 hours after the procedure
- B. Notify the provider if the end of the penis appears dark red
- C. Make sure the newborn's diaper is snug
- D. Yellow exudate will form at the surgical site in 24 hours
Correct Answer: B
Rationale: The correct answer is B: Notify the provider if the end of the penis appears dark red. This is because dark red coloration at the end of the penis could indicate infection or compromised blood flow, requiring immediate medical attention. Choice A is incorrect as the plastibell is typically left in place for about a week, not 4 hours. Choice C is incorrect as a snug diaper can cause discomfort and hinder healing. Choice D is incorrect because yellow exudate is a normal part of the healing process, usually appearing within 24-48 hours post-circumcision.