Nokea
The nurse is educating a client about Rh incompatibility. What statement indicates understanding?
- A. Rh incompatibility only occurs in first pregnancies.
- B. I will need Rho(D) immune globulin if my baby is Rh positive.
- C. Rh incompatibility is treated with antibiotics.
- D. Rh incompatibility does not affect the baby.
Correct Answer: B
Rationale: Rho(D) immune globulin prevents the mother's immune system from attacking Rh-positive fetal red blood cells.
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Which finding in a 36-week pregnant client is most concerning?
- A. Braxton Hicks contractions
- B. Frequent urination
- C. Proteinuria of +2
- D. Weight gain of 2 pounds in a week
Correct Answer: C
Rationale: Proteinuria is a sign of preeclampsia, requiring immediate assessment.
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.
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.
An African American woman noticed bruises on a newborn girl's buttocks, and she asks the nurse who spanked the baby? The nurse responds
- A. Mongolian spots
- B. Ecchymosis
- C. Birth trauma
- D. Petechiae
Correct Answer: A
Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.
As a nurse working in a prenatal clinic. It is important to obtain maternal and fetal assessing. While obtaining fetal assessments. Which of the following should the complete for fetal well-being?
- A. Fetal movement, maternal vital signs, maternal weight
- B. Fetal movement, fetal position, fetal weight
- C. Fetal position, fetal heart tone, maternal weight
- D. Fetal heart tones, fetal movement, fundal height
Correct Answer: D
Rationale: When assessing fetal well-being in a prenatal clinic, it is important to focus on factors directly related to the fetus. Fetal heart tones provide crucial information about the baby's heart rate and rhythm, indicating how well the fetus is doing. Fetal movement is another essential indicator of fetal well-being, as it shows signs of good neurological function and reactivity. Finally, measuring fundal height (the distance from the top of the uterus to the pubic bone) helps assess fetal growth and development. These three aspects - fetal heart tones, fetal movement, and fundal height - provide a comprehensive evaluation of the baby's well-being and development during pregnancy.