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The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
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A nurse is caring for a client who is 32 weeks gestation who comes to the emergency department for painful bleeding. Which is the priority nursing assessment?
- A. Monitor for contractions
- B. Assess pain level
- C. Assess for hemorrhage
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Assess for hemorrhage. This is the priority assessment as the client is experiencing painful bleeding, indicating a potential hemorrhage which can be life-threatening. Assessing for hemorrhage will help identify the severity of the situation and guide immediate interventions. Monitoring for contractions (choice A) is important but assessing for hemorrhage takes precedence. Assessing pain level (choice B) is important but addressing the potential hemorrhage is more critical. Providing emotional support (choice D) is important but should come after addressing the urgent medical need of assessing for hemorrhage.
The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.
- A. Changing cat litter
- B. Frequent vaginal examination during labor
- C. Gestational diabetes
- D. Preterm premature rupture of the membranes
Correct Answer: A
Rationale: The correct answer is A: Changing cat litter. Chorioamnionitis is an infection of the amniotic fluid and membranes. Changing cat litter exposes the woman to toxoplasmosis, a risk factor for chorioamnionitis. Choices B, C, and D are incorrect. Vaginal exams during labor can introduce bacteria but are not a direct risk factor. Gestational diabetes is unrelated, and preterm premature rupture of membranes can increase infection risk but is not a direct cause like exposure to toxoplasmosis.
A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
- A. Blood pressure of 155/95
- B. Urinary output is greater than 30 mL/hr
- C. Deep tendon reflexes +2
- D. Client complains of blurred vision
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A blood pressure of 155/95 indicates hypertension, a key feature of worsening pre-eclampsia. Hypertension in pre-eclampsia can lead to serious complications like eclampsia. High blood pressure can put the client at risk for seizures, stroke, and organ damage.
Incorrect choices:
B: Urinary output > 30 mL/hr is a positive sign, indicating adequate renal function, which is desirable in pre-eclampsia.
C: Deep tendon reflexes +2 are within normal limits and do not necessarily indicate worsening pre-eclampsia.
D: Blurred vision is a common symptom of pre-eclampsia but not a definitive sign of worsening condition.
The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
- A. Administering antiretroviral drugs as ordered
- B. Assisting the woman on a labor ball to help with natural descent of the fetus
- C. Handling the newborn with gloves until it receives its first bath
- D. Encouraging the mother to breastfeed soon after delivery
Correct Answer: A
Rationale: The correct answer is A because administering antiretroviral drugs as ordered helps reduce the risk of vertical transmission of HIV from mother to baby during childbirth. This treatment is essential in managing the client's HIV status and ensuring the safety of the newborn.
Choice B is incorrect because using a labor ball does not directly address the HIV status of the client or the transmission risk to the newborn.
Choice C is incorrect as wearing gloves when handling the newborn does not replace the need for antiretroviral therapy to prevent transmission.
Choice D is incorrect because breastfeeding can transmit HIV from mother to baby, so it is not recommended for HIV-positive mothers to breastfeed.
The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick reading of 3+ for protein indicates significant proteinuria, which can be a sign of preeclampsia in pregnancy. Preeclampsia poses serious risks to both the mother and the fetus, requiring immediate medical intervention.
Choice A: Hemoglobin and hematocrit levels within normal range for pregnancy.
Choice B: Blood pressure slightly elevated but not concerning at this gestational age.
Choice C: Slight pedal swelling is common in pregnancy and may not indicate a serious issue at this time.