Nokea
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
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Medication that are contraindicated for management of PPH include SATA (Cytotec, Hemabate, Pitocin, Methergine all for PPH)
- A. Terbutaline (for preterm labor)
- B. Magnesium sulfate
- C. Methergine
- D. Pitocin
Correct Answer: A
Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
- A. Place the client in the lateral position.
- B. Increase the rate of maintenance IV infusion.
- C. Elevate the client's legs.
Correct Answer: A
Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.
A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?
- A. Administer tocolytic medication as prescribed.
- B. Perform a sterile vaginal examination.
- C. Assess for cervical changes and fetal heart rate.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing cervical changes and fetal heart rate is essential to determine whether the client is in preterm labor.
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma regain
- C. Prothrombin time
- D. Urine culture
Correct Answer: A
Rationale: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. One important laboratory test that the nurse should anticipate for a client with hyperemesis gravidarum is the urine ketones test. Ketones in the urine can indicate that the body is breaking down fat for energy instead of using glucose, which can occur during prolonged fasting or in conditions like hyperemesis gravidarum where there is severe vomiting leading to inadequate intake of nutrients. Monitoring urine ketones levels helps healthcare providers assess the severity of dehydration and metabolic derangement in these patients. It guides the management of fluid and electrolyte replacement to prevent complications like ketosis and metabolic acidosis.
A pregnant woman tells the nurse-midwife, 'I've heard that if I eat certain foods during my pregnancy, the baby will be a boy.' The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time?
- A. At the time of ejaculation
- B. At the time of fertilization
- C. At the time of implantation
- D. At the time of differentiation
Correct Answer: B
Rationale: The sex of a baby is determined at fertilization. Sperm cells carry either an X or Y chromosome, while the ovum only carries an X chromosome. If the sperm contributes an X chromosome, the baby will be female, and if it contributes a Y chromosome, the baby will be male.