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The nurse is educating a G1P0 client who is 34 weeks in the third trimester. gestation and in her third trimester. Which of the
- A. I should gain 3.5 to 5 pounds in the first following educational topics would be appropriate trimester and 1 pound per week in the last two at this time? Select all that apply. trimesters.
- B. Contraception options after delivery
- C. I should gain 10 pounds in the first trimester,
- D. Group B strep (GBS) screen before onset of labor 10 pounds in the second trimester, and 10 pounds
Correct Answer: A
Rationale: I should gain 3.5 to 5 pounds in the first trimester and 1 pound per week in the last two trimesters.
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The nurse is assessing a client with ruptured membranes. What finding suggests chorioamnionitis?
- A. Clear amniotic fluid.
- B. Foul-smelling vaginal discharge.
- C. Fetal heart rate of 140 beats/minute.
- D. Absence of maternal fever.
Correct Answer: B
Rationale: Foul-smelling discharge is a key indicator of chorioamnionitis, an infection of the amniotic fluid.
A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct Answer: A
Rationale: Respiratory acidosis is characterized by an increase in carbon dioxide levels in the blood, leading to acidosis. This condition can affect the heart's electrical conduction system, resulting in widened QRS complexes on an electrocardiogram (ECG). Hyperactive deep tendon reflexes, bounding peripheral pulses, and warm, flushed skin are not typically associated with respiratory acidosis.
The nurse is attempting to explain physiologic birth. What do they say?
- A. Physiologic birth involves interventions that do not harm the baby.â€
- B. Physiologic birth occurs only in birth centers.â€
- C. If your partner and I give you support, you can have a birth without medical intervention.â€
- D. If you want to have a cesarean birth, we can ask your health-care provider to schedule it.â€
Correct Answer: C
Rationale: Physiologic birth focuses on minimal intervention, supported by a calm environment and supportive care.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
- D. Encourage the client to ambulate twice per day.
Correct Answer: B
Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.