Nokea
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. Thiamine deficiency can lead to Wernicke’s encephalopathy in patients with severe hyperemesis gravidarum due to poor nutrient absorption and inadequate dietary intake. This condition can cause neurological symptoms like confusion and ataxia. Folic acid (A) deficiency is common in pregnancy but is not directly related to Wernicke's encephalopathy. Vitamin D (B) deficiency is associated with bone health and immune function, not neurological symptoms. Glucose (D) is important for energy production but is not directly linked to Wernicke's encephalopathy. Checking thiamine levels is crucial to prevent neurological complications in this client.
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The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: The correct answer is A: Changing cat litter. Chorioamnionitis is an infection of the amniotic fluid and membranes. Changing cat litter exposes the woman to toxoplasmosis, a risk factor for chorioamnionitis. Choices B, C, and D are incorrect. Vaginal exams during labor can introduce bacteria but are not a direct risk factor. Gestational diabetes is unrelated, and preterm premature rupture of membranes can increase infection risk but is not a direct cause like exposure to toxoplasmosis.
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.
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.
Which factor places the client at the highest risk of pre-eclampsia?
- A. White race
- B. Multiparity
- C. Obesity
- D. Infertility
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a major risk factor for pre-eclampsia due to the increased strain on the cardiovascular system, leading to hypertension and other complications during pregnancy. Multiparity (B) is associated with a lower risk of pre-eclampsia, as previous pregnancies can provide some level of protection. Infertility (D) is not a known risk factor for pre-eclampsia. White race (A) is not a definitive risk factor for pre-eclampsia, as it can affect individuals of all races.