Nokea
The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks' gestation. What intervention will the nurse implement before this diagnostic test?
- A. Instruct the patient to take nothing by mouth after midnight the night before the test.
- B. Initiate an IV.
- C. Encourage the patient to drink 1 to 2 quarts of water before the test.
- D. Instruct the patient to remove all jewelry.
Correct Answer: C
Rationale: Ultrasound uses high-frequency sound waves to visualize structures within the body; the examination may use a transvaginal probe or an abdominal transducer; abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination).
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The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication?
- A. Abdominal enlargement
- B. Facial swelling
- C. Sudden weight gain
- D. Swelling of the feet and ankles
Correct Answer: C
Rationale: Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs, and hands follow weight gain.
The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse?
- A. There is usually something wrong with the fetus when this happens early in pregnancy.'
- B. Now there. You can try to conceive on your next cycle.'
- C. I'm here if you need to talk.'
- D. You are young and strong. I know you can have a healthy pregnancy.'
Correct Answer: C
Rationale: An effective technique when communicating with a woman experiencing pregnancy loss is to say, 'I'm here if you need to talk.' The nurse listens and acknowledges the woman's grief.
What symptom presented by a pregnant woman is indicative of abruptio placentae?
- A. Painless vaginal bleeding
- B. Uterine irritability with contractions
- C. Vaginal bleeding and back pain
- D. Premature rupture of membranes
Correct Answer: C
Rationale: Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae.
What situation would concern the nurse about the presence of Rh incompatibility?
- A. Rh-negative mother, Rh-positive fetus
- B. Rh-positive mother, Rh-negative fetus
- C. Rh-negative mother, Rh-negative fetus
- D. Rh-positive mother, Rh-positive fetus
Correct Answer: A
Rationale: Rh incompatibility can occur only if the mother is Rh negative and the fetus is Rh positive.
A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.)
- A. Privacy
- B. An opportunity to hold the infant
- C. Materials about support groups
- D. A memento (footprint or lock of hair)
- E. A warm beverage
Correct Answer: A,B,C,D
Rationale: The patient should be offered privacy, an opportunity to hold the infant, support group information, and a memento. A warm beverage is not a priority at this time.