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A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.
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The nurse is assessing a client at 10 weeks' gestation with hyperemesis gravidarum. What is the priority nursing action?
- A. Encourage small, frequent meals.
- B. Monitor for signs of dehydration.
- C. Administer antiemetics as prescribed.
- D. Encourage fluid intake between meals.
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of dehydration. Dehydration is a serious complication of hyperemesis gravidarum and can lead to electrolyte imbalances and maternal-fetal complications. By monitoring for signs of dehydration, the nurse can intervene promptly to prevent further complications. Encouraging small, frequent meals (choice A) may help manage nausea but does not address the risk of dehydration. Administering antiemetics (choice C) may be necessary, but monitoring for dehydration takes precedence. Encouraging fluid intake between meals (choice D) is important, but assessing for dehydration is more critical in this situation.
The nurse is teaching a client about postpartum care. Which statement indicates a need for further teaching?
- A. I will avoid heavy lifting for 6 weeks.
- B. It’s normal to have heavy bleeding for 4 weeks.
- C. I will call my doctor if I develop a fever.
- D. I should continue taking my prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because heavy bleeding for 4 weeks postpartum is abnormal and could indicate a complication. The client should seek medical attention if experiencing heavy bleeding beyond the normal range. Choices A, C, and D are all correct statements for postpartum care. A - avoiding heavy lifting helps prevent strain on healing tissues, C - fever could indicate infection, and D - continuing prenatal vitamins supports postpartum recovery.
The nurse is educating a client about postpartum warning signs. Which symptom requires immediate medical attention?
- A. Increased lochia after breastfeeding.
- B. Perineal discomfort on day 3 postpartum.
- C. Fever of 101°F and foul-smelling lochia.
- D. Mild fatigue and trouble sleeping.
Correct Answer: C
Rationale: The correct answer is C: Fever of 101°F and foul-smelling lochia. This combination indicates a possible infection like endometritis, which can be life-threatening if not promptly treated. Fever is a sign of systemic infection, and foul-smelling lochia suggests an infected uterus. Immediate medical attention is crucial to prevent complications.
A: Increased lochia after breastfeeding is common and not necessarily alarming unless it is excessive or accompanied by other symptoms.
B: Perineal discomfort on day 3 postpartum is expected due to the healing process and does not typically require immediate medical attention.
D: Mild fatigue and trouble sleeping are common postpartum symptoms but do not indicate a medical emergency unless they are severe or persistent.
The nurse is educating a client about Braxton Hicks contractions. Which statement indicates proper understanding?
- A. They are regular and increase in intensity over time.
- B. They are irregular and usually painless.
- C. They indicate that labor is starting.
- D. They require immediate medical attention.
Correct Answer: B
Rationale: The correct answer is B because Braxton Hicks contractions are indeed irregular and typically painless contractions that occur throughout pregnancy. They are considered practice contractions and do not indicate the onset of labor. Choice A is incorrect as Braxton Hicks contractions are not regular or increasing in intensity. Choice C is incorrect because Braxton Hicks contractions do not signal the start of labor. Choice D is also incorrect as Braxton Hicks contractions are a normal part of pregnancy and do not require immediate medical attention.
Which is a disadvantage of the progesterone-only contraception pill?
- A. Side effects could be increased for persons who are underweight.
- B. There could be a decrease in bone mineral density over time.
- C. They may cause irregular bleeding and spotting.
- D. Return to fertility after discontinuing the pill may take several months.
Correct Answer: B
Rationale: The correct answer is B: There could be a decrease in bone mineral density over time. Progesterone-only pills have been associated with a potential decrease in bone density, especially with long-term use. This is because progesterone can have a negative impact on calcium absorption, leading to bone weakening.
A: Side effects could be increased for persons who are underweight - This is not a specific disadvantage of progesterone-only pills and can apply to any contraceptive method.
C: They may cause irregular bleeding and spotting - This is a common side effect of progesterone-only pills but not a significant disadvantage compared to bone density issues.
D: Return to fertility after discontinuing the pill may take several months - This is a temporary effect and not a long-term disadvantage like decreased bone density.