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The nurse is monitoring a client with gestational hypertension. What symptom requires immediate intervention?
- A. Weight gain of 1 pound in a week.
- B. Slight swelling of the hands and feet.
- C. Severe headache and vision changes.
- D. Blood pressure of 135/85 mmHg.
Correct Answer: C
Rationale: Severe headache and vision changes may indicate preeclampsia and require immediate evaluation.
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The nurse is educating a client with gestational hypertension about home care. What instruction should the nurse include?
- A. Monitor your blood pressure once a week.
- B. Report any sudden swelling or weight gain.
- C. Increase sodium intake to maintain hydration.
- D. Avoid taking daily medications.
Correct Answer: B
Rationale: Sudden swelling or rapid weight gain may indicate worsening gestational hypertension or preeclampsia.
During preconception counseling the nurse explains the time-period as when the fetus is most vulnerable to the effects of teratogens occurs is which of the following?
- A. 2 to 8 weeks
- B. 4 to12 weeks
- C. 5 to 10 weeks
- D. 6 to 15 weeks
Correct Answer: A
Rationale: The time period when the fetus is most vulnerable to the effects of teratogens is considered to be between weeks 2 to 8 of pregnancy. This period is known as the embryonic period, during which the organs and major body systems are forming. Exposure to teratogens during this time can lead to structural abnormalities or birth defects. It is crucial for women to be aware of this critical window of susceptibility during preconception counseling to avoid potential harm to the developing fetus.
To prevent breast engorgement a new breastfeeding mother should be instructed to:
- A. Apply cold packs to the breast before feeding
- B. Breastfeed frequently and for adequate lengths of time to empty the breasts.
- C. Limit her intake of fluids for a few days
- D. Feed her infant no more than every 4 hours
Correct Answer: B
Rationale: Frequent breastfeeding helps prevent engorgement.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
What advice should the nurse give if a woman forgets to take a low-dose combination birth control pill?
- A. Take it as soon as she remembers, even if that means taking two pills in one day.
- B. Skip that pill and refrain from intercourse for the remainder of the month.
- C. Wear a pad for the next week because she will experience vaginal bleeding.
- D. Take an at-home pregnancy test at the end of the month to check for a pregnancy.
Correct Answer: A
Rationale: Taking the missed pill promptly minimizes contraceptive failure.