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The nurse is discussing danger signs during preg- tion procedure. Which statement is appropriate for nancy with a pregnant woman in her first trimester. the nurse to make? Which of the following signs and symptoms would
- A. A catheter is inserted through the cervix into the be appropriate at this time? Select all that apply.
- B. Severe headache and visual changes
- C. Persistent vomiting and nausea
- D. Sperm or ovarian tissue will be frozen for
Correct Answer: B
Rationale: The correct answer is B. Severe headache and visual changes are potential danger signs during the first trimester of pregnancy, indicating conditions like preeclampsia. This is crucial to monitor as it can lead to serious complications for both the mother and the baby.
Choice A is incorrect because inserting a catheter through the cervix is not a relevant danger sign during the first trimester. Choice C, persistent vomiting and nausea, is commonly experienced in the first trimester as morning sickness and is not typically a sign of immediate danger. Choice D, freezing sperm or ovarian tissue, is unrelated to discussing danger signs during pregnancy and does not indicate any potential issues during the first trimester.
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The nurse is assessing a client in the third trimester with suspected gestational diabetes. What symptom is most concerning?
- A. Increased thirst and urination.
- B. Fasting blood glucose of 100 mg/dL.
- C. Weight gain of 1 pound in a week.
- D. Proteinuria of +1.
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and urination. In gestational diabetes, increased thirst and urination can indicate uncontrolled blood sugar levels, which can harm the fetus. This symptom suggests hyperglycemia and requires immediate intervention.
B: Fasting blood glucose of 100 mg/dL is within the normal range for pregnancy and not concerning.
C: Weight gain of 1 pound in a week can be normal in the third trimester and not specific to gestational diabetes.
D: Proteinuria of +1 is more concerning for preeclampsia rather than gestational diabetes.
A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.
A patient has had four vaginal deliveries. What barrier contraceptive method’s efficacy is affected by this history?
- A. internal condom
- B. external condom
- C. cervical cap
- D. contraceptive gel
Correct Answer: C
Rationale: The correct answer is C: cervical cap. This barrier contraceptive method's efficacy is affected by the patient's history of four vaginal deliveries due to changes in the cervix and vaginal canal post-deliveries. The cervical cap relies on proper placement over the cervix to prevent sperm from entering the uterus. However, after multiple vaginal deliveries, the cervix may become less firm and may have altered shape or size, leading to reduced effectiveness of the cervical cap.
A: Internal condom and B: external condom are not affected by the history of vaginal deliveries as they do not rely on cervical fit for efficacy.
D: Contraceptive gel is not directly affected by the number of vaginal deliveries as it is applied externally and does not rely on cervical anatomy for effectiveness.