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The nurse is reviewing lab results for a pregnant client. Which finding is most concerning?
- A. Hemoglobin of 11 g/dL.
- B. WBC count of 14,000 mm3.
- C. Platelet count of 90,000 mm3.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: Platelet count of 90,000 mm3. A low platelet count (thrombocytopenia) in pregnancy can lead to serious complications like bleeding disorders or preeclampsia. Hemoglobin level of 11 g/dL is within normal range for pregnancy. WBC count of 14,000 mm3 may indicate infection but is not as concerning as thrombocytopenia. Fasting blood glucose of 90 mg/dL is also normal in pregnancy.
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Which is a disadvantage of the progesterone-only contraception pill?
- A. Side effects could be increased for persons who are underweight.
- B. There could be a decrease in bone mineral density over time.
- C. They may cause irregular bleeding and spotting.
- D. Return to fertility after discontinuing the pill may take several months.
Correct Answer: B
Rationale: The correct answer is B: There could be a decrease in bone mineral density over time. Progesterone-only pills have been associated with a potential decrease in bone density, especially with long-term use. This is because progesterone can have a negative impact on calcium absorption, leading to bone weakening.
A: Side effects could be increased for persons who are underweight - This is not a specific disadvantage of progesterone-only pills and can apply to any contraceptive method.
C: They may cause irregular bleeding and spotting - This is a common side effect of progesterone-only pills but not a significant disadvantage compared to bone density issues.
D: Return to fertility after discontinuing the pill may take several months - This is a temporary effect and not a long-term disadvantage like decreased bone density.
The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.
What do you give for magnesium sulfate toxicity?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Furosemide (Lasix)
- D. Vitamin K
Correct Answer: A
Rationale: The correct answer is A: Calcium gluconate. In magnesium sulfate toxicity, high levels of magnesium can lead to muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is given because it antagonizes the effects of magnesium on the neuromuscular system and helps prevent further complications. Sodium bicarbonate (B) is not the correct choice as it is used to treat acidosis, not magnesium toxicity. Furosemide (C) is a diuretic and would not address magnesium toxicity. Vitamin K (D) is used for blood clotting disorders, not for magnesium toxicity.
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Prepare for insertion of an intrauterine pressure catheter.
- D. Assist the client into the knee-chest position.
Correct Answer: D
Rationale: The correct answer is D: Assist the client into the knee-chest position. This position helps relieve pressure on the umbilical cord, preventing compression and potential harm to the fetus. By positioning the client in knee-chest, gravity can aid in moving the fetus off the cord. Administering oxytocin (choice A) is not appropriate as the priority is to relieve pressure on the cord. Applying oxygen (choice B) does not address the immediate risk posed by the cord prolapse. Insertion of an intrauterine pressure catheter (choice C) is not indicated when the priority is to alleviate cord compression.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding?
- A. It connects the pulmonary artery to the aorta.
- B. It is an opening between the right and left atria.
- C. It connects the umbilical vein to the inferior vena cava.
- D. It connects the umbilical artery to the inferior vena cava.
Correct Answer: C
Rationale: The correct answer is C because the ductus venosus is a fetal vessel that connects the umbilical vein to the inferior vena cava, allowing oxygenated blood from the placenta to bypass the liver and flow directly to the fetal heart. Choice A is incorrect because the ductus arteriosus connects the pulmonary artery to the aorta. Choice B is incorrect as it refers to the foramen ovale, which is an opening between the right and left atria. Choice D is incorrect as it describes the ductus deferens, a part of the male reproductive system.