Nokea
The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results?
- A. Platelets 200,000 mm3.
- B. Lactate dehydrogenase(LDH)> 200 units/L.
- C. Uric acid 3 mg/dL.
- D. Aspartate aminotransferase(AST) 15 units/L.
Correct Answer: B
Rationale: Elevated LDH indicates possible hemolysis in HELLP syndrome.
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Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.
After a dilatation and curettage(D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
- A. Urinary tract infection.
- B. Hemorrhage.
- C. Abdominal distention.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: Hemorrhage is a potential complication after D&C.
A 16-year-old client at 34 weeks' gestation, who is being monitored at home with home nursing visits, is diagnosed with mild preeclampsia and has gained 2 lb in the past week. Her current blood pressure is 144/92 mm Hg. Which assessment finding would require further action by the home health nurse?
- A. Occasional headache.
- B. Frequent voiding in large amounts.
- C. 1+ pedal edema.
- D. 3+ protein on urine dipstick.
Correct Answer: D
Rationale: Significant proteinuria suggests worsening preeclampsia.
The nurse is caring for a primigravid client in active labor at 42 weeks' gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by:
- A. Changing her pushing position every 15 minutes.
- B. Notifying the health care provider of her current status.
- C. Continuing with current pushing technique.
- D. Assessing the client's current pain and fetal status.
Correct Answer: D
Rationale: Prolonged pushing (2 hours) in a primigravid client at 42 weeks requires assessment of pain and fetal status to identify potential complications like exhaustion or fetal distress. Changing positions may help but is less urgent, notifying the provider is premature without assessment, and continuing the current technique may not address underlying issues.
A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? Select all that apply.
- A. -2 station.
- B. Low birth weight infant.
- C. Rupture of membranes.
- D. Breech presentation.
- E. Prior abortion.
- F. Low lying placenta.
Correct Answer: A,B,C,D,F
Rationale: These factors increase the risk of cord prolapse.