Nokea
The nurse is caring for the client admitted to the antepartum unit at 32 weeks’ gestation with possible preterm labor. The nurse is performing a fetal fibronectin (fFN) test. Which event, if it occurred, would require the nurse to recollect the specimen?
- A. The specimen is collected before a vaginal examination.
- B. A lubricant was used to facilitate insertion of the swab.
- C. The client reports that she has not had intercourse for 3 days.
- D. The specimen is collected before other specimens are collected.
Correct Answer: B
Rationale: When collecting a fetal fibronectin test swab, the nurse must not use lubricant, as it will interfere with the collection of the specimen and contaminate the specimen. If this occurs, the test will need to be repeated. The specimen needs to be collected before a vaginal examination in order to ensure that the fluids are not contaminated. The client must not have had sexual intercourse within 24 hours of the specimen collection, as semen will contaminate the specimen. The specimen must be collected before other specimens are collected to maintain the integrity of the specimen.
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The nurse prepares the client for which pain management option during labor?
- A. Epidural anesthesia
- B. Hot baths during active labor
- C. Over-the-counter pain relievers
- D. No pain relief options
Correct Answer: A
Rationale: Epidural anesthesia is a common and effective pain management option during labor, tailored to the client's needs.
The full-term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/96 mm Hg, and her pulse is 109 bpm. The nurse should immediately implement interventions for which possible complication?
- A. Placenta previa
- B. Placental abruption
- C. Bloody show
- D. Succenturiate placenta
Correct Answer: B
Rationale: The nurse should immediately implement interventions for placental abruption. This occurs when the placenta separates from the uterine wall before the birth of the fetus. It is commonly associated with preeclampsia. Placenta previa is marked by painless vaginal bleeding. Bloody show is a normal physiological sign associated with normal labor progression and is marked by bloody, mucuslike consistency. Succenturiate placenta is the presence of one or more accessory lobes that develop on the placenta with vascular connections of fetal origin.
The first-trimester pregnant client asks the nurse if the activities in which she participates are safe in the first trimester. Which activity should the nurse verify as a safe activity during the client’s first trimester?
- A. Hair coloring
- B. Hot tub use
- C. Pesticide use
- D. Sexual activity
Correct Answer: D
Rationale: Sexual activity is not contraindicated in pregnancy unless a specific risk factor is identified. Hair coloring should be avoided in the first trimester because the chemicals can be absorbed and pose a risk to the developing fetus. Hot tub use should be avoided because it increases the client’s body temperature. Maternal hyperthermia during the first trimester raises concerns about possible spontaneous abortion, CNS defects, and failure of neural tube closure. Exposure to pesticides during pregnancy increases the risk for preterm birth, intrauterine growth restriction, childhood developmental delays, and infertility later in adulthood.
The postpartum client’s blood type is A negative, and her newborn infant’s blood type is AB negative. The client received RhoGAM in her second trimester and another dose in her third trimester, after a minor car accident. The client is preparing for discharge and asks the nurse when she will receive her RhoGAM injection. The nurse correctly responds with which statement?
- A. “You already received two doses of RhoGAM and do not need an additional dose.”
- B. “I will give your last dose of RhoGAM today, before you are discharged to home.”
- C. “You and your baby have negative blood types; a dose of RhoGAM is not needed.”
- D. “RhoGAM would have been already given while you were in the delivery room.”
Correct Answer: C
Rationale: The number of RhoGAM doses given in pregnancy does not affect whether or not the client receives a dose postpartum. Both the client and newborn are Rh negative; no dose is required. Rh immune globulin (RhoGAM) is administered to women with Rh negative blood types at approximately 28 weeks of gestation and again after any trauma, such as a car accident or fall. After delivery, RhoGAM is only indicated if the newborn has a positive blood type; both the client and newborn are Rh negative. For postpartum clients who require RhoGAM, the dose is given within 72 hours of delivery. However, no dose is necessary because the client and newborn are both Rh negative.
The nurse identifies which factor as increasing the risk of gestational hypertension?
- A. Low body mass index
- B. Family history of hypertension
- C. First pregnancy at age 20
- D. Vegetarian diet
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.