Nokea
A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse?
- A. "It burns when I urinate
- B. "My feet are really swollen today".
- C. "didn't have lunch today, but I have breakfast this morning".
- D. "have been seeing spot this morning"
Correct Answer: D
Rationale: Seeing spots or experiencing visual disturbances can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. Preeclampsia can lead to severe complications for both the mother and the baby, so it requires immediate intervention by the nurse. The other statements made by the client are concerning but do not indicate an urgent need for intervention compared to the symptoms of preeclampsia.
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Which is the most dangerous effect on the fetus of a patient who smokes cigarettes while pregnant?
- A. Intrauterine growth restriction
- B. Genetic changes and anomalies
- C. Extensive central nervous system damage
- D. Fetal addiction to the substance inhaled
Correct Answer: A
Rationale: Smoking cigarettes during pregnancy is known to have harmful effects on the fetus, with one of the most serious consequences being intrauterine growth restriction (IUGR). IUGR occurs when the fetus does not grow at a normal rate inside the womb, leading to a lower birth weight. This can have long-term implications on the overall health and development of the baby, including increased risk of various health problems later in life such as respiratory issues, cardiovascular disease, and metabolic disorders. In severe cases, IUGR can even result in stillbirth or neonatal death. Therefore, it is crucial for pregnant individuals to avoid smoking to protect the health and well-being of their unborn child.
A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)
- A. Prostaglandin E2
- B. Indomethacin
- C. Magnesium sulfate
- D. Methylergonovine
Correct Answer: A
Rationale: A. Prostaglandin E2: Prostaglandin E2 is used to manage preterm labor by helping to ripen the cervix and promote contractions.
A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following?
- A. Estrogen
- B. Human chorionic gonadotropin (hCG)
- C. Progesterone
- D. Luteinizing hormone
Correct Answer: B
Rationale: hCG is a hormone secreted by the fertilized egg shortly after implantation. It signals the body to maintain the corpus luteum, which produces progesterone essential for sustaining the early stages of pregnancy.
The nurse is teaching a client with preeclampsia about home care. Which statement indicates understanding?
- A. I should monitor my blood pressure once a week.
- B. I should limit my fluid intake to reduce swelling.
- C. I will report any headache or vision changes immediately.
- D. I can exercise daily to maintain health.
Correct Answer: C
Rationale: Headache and vision changes can signal worsening preeclampsia, requiring prompt medical attention.
The nurse is assessing a client with suspected gestational hypertension. What finding supports this diagnosis?
- A. Blood pressure of 150/90 mmHg.
- B. Proteinuria of +2.
- C. Fetal heart rate of 140 beats/minute.
- D. Mild edema in the lower extremities.
Correct Answer: A
Rationale: Gestational hypertension is diagnosed with a blood pressure of 140/90 mmHg or higher without proteinuria.