Nokea
The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
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What is the nurse's role in supporting breastfeeding for a first-time mother?
- A. Provide formula supplements
- B. Demonstrate proper latching techniques
- C. Recommend stopping breastfeeding
- D. Provide pacifiers to prevent overfeeding
Correct Answer: A
Rationale: Proper latching techniques help establish successful breastfeeding and prevent complications.
What is the most common sign/symptom of sexually transmitted infections?
- A. Menstrual cramping.
- B. Heavy menstrual periods.
- C. Flu-like symptoms.
- D. Lack of signs or symptoms.
Correct Answer: D
Rationale: Many STIs are asymptomatic, making regular screening important.
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: D
Rationale: Fluid loss is the primary cause of early weight loss.
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.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr.
- B. Creatinine 0.8 mg/ Dl
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.