Nokea
The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
- A. Proteinuria.
- B. Blood pressure of 140/90 mmHg on two occasions.
- C. Edema of the hands and feet.
- D. Elevated blood glucose levels.
Correct Answer: B
Rationale: Gestational hypertension is diagnosed by consistent readings of 140/90 mmHg or higher without proteinuria.
You may also like to solve these questions
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.
The nurse is monitoring a postpartum client with a boggy uterus. What is the priority intervention?
- A. Notify the healthcare provider.
- B. Massage the fundus until firm.
- C. Administer prescribed oxytocin.
- D. Check the client’s vital signs.
Correct Answer: B
Rationale: Massaging a boggy uterus stimulates contraction and reduces the risk of postpartum hemorrhage.
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.
Which complication of adolescent pregnancy should the nurse plan to monitor?
- A. Anemia
- B. Placenta previa
- C. Abruptio placenta
- D. Incompetent cervix
Correct Answer: D
Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."