Nokea
The nurse is caring for the client with mild preeclampsia. The nurse should monitor for which complications associated with mild preeclampsia? Select all that apply.
- A. Placental abruption
- B. Hyperbilirubinemia
- C. Nonreassuring fetal status
- D. Severe preeclampsia
- E. Gestational diabetes
Correct Answer: A,B,C,D
Rationale: Placental abruption can occur as a complication of preeclampsia due to hypoperfusion of the placenta and endothelial injury. Hyperbilirubinemia can occur as a complication of preeclampsia due to hypoperfusion to the liver. Nonreassuring fetal status can occur as a complication of preeclampsia due to hypoperfusion to the placenta. Severe preeclampsia can occur as a complication of preeclampsia if the BP remains uncontrolled. Gestational diabetes is not associated with preeclampsia.
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The nurse instructs the client with hyperemesis gravidarum to avoid which trigger?
- A. Eating small, frequent meals
- B. Strong odors
- C. High-protein foods
- D. Adequate hydration
Correct Answer: B
Rationale: Strong odors can exacerbate nausea and vomiting in hyperemesis gravidarum, worsening symptoms.
The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
- A. Umbilical cord prolapse
- B. Transverse fetal lie
- C. Cervical dilation not progressing
- D. Premature rupture of membranes
- E. Previous cesarean incision
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
- A. 5 months
- B. 6 months
- C. 7 months
- D. 8 months
Correct Answer: A
Rationale: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
The 28-year-old pregnant client (G3P2) has just been diagnosed with gestational diabetes at 30 weeks. The client asks what types of complications may occur with this diagnosis. Which complications should the nurse identify as being associated with gestational diabetes? Select all that apply.
- A. Seizures
- B. Large-for-gestational-age infant
- C. Low-birth-weight infant
- D. Congenital anomalies
- E. Preterm labor
Correct Answer: B,D
Rationale: Infants of diabetic mothers can be large as a result of excess glucose to the fetus. Congenital anomalies are more common in diabetic pregnancies. Seizures do not occur as a result of diabetes but can be associated with preeclampsia, another pregnancy complication. Infants of diabetic mothers are usually large for gestational age and do not have a low birth weight. Preterm labor is not typically associated with maternal diabetes.
The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
- A. Client who is 2 hours post-cesarean birth for a breech baby
- B. Client who delivered a macrosomic baby after a 12-hour labor
- C. Client who has a firm fundus after a vaginal delivery 4 hours ago
- D. Client receiving oxytocin intravenously for past 2 hours
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.