Nokea
The nurse is caring for a client with preeclampsia. What is the most important assessment?
- A. Daily weight.
- B. Urine protein levels.
- C. Fetal heart rate.
- D. Blood pressure.
Correct Answer: D
Rationale: Blood pressure monitoring is critical to prevent complications such as eclampsia and placental issues in preeclampsia.
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The nurse is assessing a client at 20 weeks' gestation with suspected anemia. What lab finding supports this diagnosis?
- A. Hemoglobin of 10 g/dL.
- B. Platelet count of 150,000 mm3.
- C. Hematocrit of 40%.
- D. White blood cell count of 8,000 mm3.
Correct Answer: A
Rationale: A hemoglobin level of 10 g/dL is below normal during pregnancy and indicates anemia.
The nurse is caring for a client with gestational hypertension. What symptom should be reported immediately?
- A. Headache unrelieved by acetaminophen.
- B. Slight swelling of the hands.
- C. Mild nausea after eating.
- D. Fatigue at the end of the day.
Correct Answer: A
Rationale: Headache unrelieved by medication may indicate worsening gestational hypertension or preeclampsia.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
- A. Meconium "“ start fluid
- B. Placenta previa
- C. Midline episiotomy
- D. Gestational hypertension
Correct Answer: C
Rationale: A midline episiotomy increases the risk for infection in postpartum clients due to the incision made in the perineum during childbirth. This incision can serve as a portal of entry for microorganisms, leading to an increased risk of infection. Meconium-stained amniotic fluid (choice A) can increase the risk of respiratory distress in the newborn but is not directly related to infection in the postpartum client. Placenta previa (choice B) is a condition during pregnancy where the placenta partially or completely covers the cervix, which poses risks related to bleeding rather than infection postpartum. Gestational hypertension (choice D) is a risk factor for developing preeclampsia or eclampsia during pregnancy but does not directly increase the risk of infection in the postpartum period.
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
- A. Wide, staring eye
- B. Transparent, red skin
- C. An absence of lanugo
- D. A scrotum with descended testicles
Correct Answer: B
Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.
The nurse is monitoring a client receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2 minutes.
- B. Fetal heart rate of 100 beats/minute.
- C. Maternal blood pressure of 120/80 mmHg.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: A fetal heart rate of 100 bpm indicates bradycardia and requires immediate discontinuation of oxytocin.