Nokea
Client immediate postoperative period, removal of ectopic pregnancy via salpingostomy
The nurse should prepare to administer Rho(D) immune globulin (RhoGAM or RhiG) as prescribed if the record indicates that the client
- A. has previously given birth to an Rh-negative infant.
- B. has had significant blood loss during the procedure.
- C. has expressed a desire to conceive again.
- D. is Rh-negative.
Correct Answer: D
Rationale: The correct answer is D because Rho(D) immune globulin is administered to Rh-negative mothers to prevent hemolytic disease of the newborn in future pregnancies with Rh-positive infants. Choice A is incorrect because having an Rh-negative infant does not warrant the administration of RhoGAM. Choice B is incorrect because significant blood loss does not relate to the need for RhoGAM. Choice C is incorrect as the desire to conceive again does not indicate the necessity for RhoGAM administration.
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Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.
Client at 28 weeks of gestation, history of one elective abortion at 9 weeks, birth of twins at 36 weeks, spontaneous abortion at 15 weeks
According to the GTPAL system, which of the following describes her present parity?
- A. 4-0-0-2-2
- B. 4-2-0-2-2
- C. 4-0-2-2-2
- D. 4-0-1-2-2
Correct Answer: D
Rationale: According to the GTPAL system, "G" represents the total number of pregnancies. In this case, the correct answer is D (4-0-1-2-2) because it indicates the woman has had 4 pregnancies, 0 term births, 1 preterm birth, 2 living children, and 2 abortions/miscarriages. This is the correct interpretation of her present parity. Choices A, B, and C have incorrect numbers for preterm births, living children, or abortions/miscarriages, making them incorrect.
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 4 hours postpartum, vaginal birth, saturated perineal pad within 10 minutes
Which of the following is the nurse's first action?
- A. Observe for pooling of blood under the buttocks.
- B. Assess client's blood pressure.
- C. Prepare to administer a prescribed oxytocic preparation.
- D. Massage the client's fundus.
Correct Answer: D
Rationale: The correct answer is D: Massage the client's fundus. This is the nurse's first action after childbirth to prevent postpartum hemorrhage by promoting uterine contractions and expelling any clots. Assessing blood pressure (B) is important but not the first action. Observing for pooling of blood under the buttocks (A) is a sign of excessive bleeding but not the first action. Administering oxytocic preparation (C) can help prevent postpartum hemorrhage, but it is not the first action.
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.