Nokea
Client might have a hydatidiform mole
The nurse should monitor the client for which of the following findings?
- A. Whitish vaginal discharge
- B. Fetal heart rate irregularities
- C. Excessive uterine enlargement
- D. Rapidly dropping human chorionic gonadotropin (hCG) levels
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. This finding is important to monitor in a pregnant client as it may indicate conditions such as multiple gestation, hydramnios, or molar pregnancy, which could pose risks to both the mother and baby. Monitoring uterine size helps in assessing fetal growth and development. Whitish vaginal discharge (A) could be a normal finding or indicate a yeast infection, while fetal heart rate irregularities (B) would be monitored using fetal monitoring, not uterine size. Rapidly dropping hCG levels (D) could suggest a miscarriage or ectopic pregnancy, but it is not directly related to uterine enlargement.
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Client in second trimester
The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?
- A. Increased abdominal muscle tone
- B. Decreased mobility of pelvic joints
- C. An increase in lordosis
- D. Posterior neck flexion
Correct Answer: C
Rationale: The correct answer is C: An increase in lordosis. During pregnancy, the center of gravity shifts forward due to the growing uterus, leading to an increase in the curvature of the lumbar spine (lordosis). This change helps to maintain balance and compensate for the added weight of the developing fetus. Increased abdominal muscle tone (choice A) is not an expected change as the abdominal muscles may actually stretch and weaken to accommodate the growing uterus. Decreased mobility of pelvic joints (choice B) is incorrect because during pregnancy, hormonal changes can actually increase the mobility of pelvic joints to prepare for childbirth. Posterior neck flexion (choice D) is unrelated to the physiologic changes in pregnancy.
Client in second trimester, new diagnosis of gestational diabetes
Which of the following statements by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of my daily caloric intake.
- B. I know I am at increased risk to develop type 2 diabetes.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I will take my glyburide daily with breakfast.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week goes against the goal of managing diabetes, which typically requires consistent physical activity. Regular exercise helps control blood sugar levels, improves insulin sensitivity, and promotes overall health. Choices A, B, and D demonstrate an understanding of diabetes management and medication adherence, indicating no need for further teaching in those areas.
Adult patient, physician orders Magnesium 4 gms loading dose to infuse over 30 minutes at 0500, then infuse a maintenance dose of 1 gram/hr, pharmacy sends 80 Gms in 1000 mL of LR
What would the nurse set the pump for the loading dose at 5 Am? Be sure to enter the number AND the unit of measurement (mL).
Correct Answer: 200 mL/hr
Rationale: The correct answer is 200 mL/hr. At 5 AM, the nurse would set the pump for the loading dose based on the prescribed rate per hour. By setting the pump at 200 mL/hr, the patient will receive the intended dose over the specified time. Choices A-G are incorrect as they do not align with the standard dosing calculations for the loading dose at 5 AM.
Client possible ectopic pregnancy at 8 weeks of gestation
Which of the following findings should the nurse expect?
- A. Pelvic pain
- B. Severe nausea and vomiting
- C. Copious vaginal bleeding
- D. Uterine enlargement greater than expected for gestational age
Correct Answer: A
Rationale: The correct answer is A: Pelvic pain. This finding is indicative of ectopic pregnancy, where the fertilized egg implants outside the uterus, often causing pelvic pain due to fallopian tube stretching or rupture. Severe nausea and vomiting (B) can occur in normal pregnancy but are not specific to ectopic pregnancy. Copious vaginal bleeding (C) is more commonly seen in miscarriage. Uterine enlargement greater than expected for gestational age (D) would be expected in a normal intrauterine pregnancy, not in ectopic pregnancy.
Client pregnant, BMI of 26.5
Which of the following statements is an appropriate response by the nurse?
- A. A gain of about 25 to 35 pounds is best for you and for your baby.
- B. The recommendation for you is about 15 to 25 pounds.
- C. You should gain 11 to 20 pounds.
- D. It really doesn't matter exactly how much weight you gain, as long as your diet is healthy.
Correct Answer: B
Rationale: The correct answer is B because the recommended weight gain during pregnancy varies based on pre-pregnancy weight. For a normal weight woman, gaining 25 to 35 pounds is ideal. However, for an underweight woman, it's recommended to gain 28 to 40 pounds, and for an overweight woman, 15 to 25 pounds is advised. Choice A is incorrect as it does not consider individual differences. Choice C is too narrow and may not be applicable to all women. Choice D is incorrect because weight gain does matter for both the mother and baby's health outcomes.