Nokea
The nurse teaches the client to recognize which early labor sign?
- A. Bloody show
- B. Fatigue
- C. Increased appetite
- D. Mild nausea
Correct Answer: A
Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.
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Which intervention is most appropriate for a client experiencing low self-esteem during pregnancy?
- A. Encourage participation in a prenatal support group
- B. Prescribe antidepressants immediately
- C. Advise avoiding social interactions
- D. Ignore the issue as it is common
Correct Answer: A
Rationale: A prenatal support group fosters peer support and boosts self-esteem, addressing the client's emotional needs.
The pregnant client has been pushing for 2½ hours. After some difficulty, the large fetal head emerges. The HCP attempts to deliver the shoulders without success. Place the nurse’s actions in caring for this client in the correct sequence.
- A. Apply suprapubic pressure per direction of the HCP.
- B. Place the client in exaggerated lithotomy position.
- C. Catheterize the client’s bladder.
- D. Call for the neonatal resuscitation team to be present.
- E. Prepare for an emergency cesarean birth.
Correct Answer: D,B,A,C,E
Rationale: Call for the neonatal resuscitation team to be present because of fetal distress. Place the client in exaggerated lithotomy position so the McRoberts’ maneuver can be performed (flexing her thighs sharply on her abdomen may widen the pelvic outlet and let the anterior shoulder be delivered). Apply suprapubic pressure per direction of the HCP. This is completed in an effort to dislodge the shoulder from under the pubic bone. Catheterize the client’s bladder. This will empty the bladder to make more room for the fetal head. Prepare for an emergency cesarean birth. This will be performed if all efforts for a vaginal birth fail.
How early in a pregnancy can the nurse expect to hear the fetal heartbeat using a Doppler device?
- A. 4 to 6 weeks
- B. 8 to 10 weeks
- C. 12 to 14 weeks
- D. 16 to 18 weeks
Correct Answer: C
Rationale: A fetal heartbeat can typically be detected by Doppler around 12-14 weeks, when the fetus is sufficiently developed.
The nurse is providing nutrition counseling to the client during her first prenatal clinical visit. Which statement, if made by the client, indicates that the client has an understanding of some of the nutritional requirements during pregnancy?
- A. “I can eat cheese as an alternative to milk, as I don’t care for milk.”
- B. “I should be eating more at each meal because I’m eating for two.”
- C. “I will need to limit my calories because I am already overweight.”
- D. “I should limit myself to eating only three healthy meals per day.”
Correct Answer: A
Rationale: Cheese is a milk product and is an alternative to milk. This statement indicates understanding of nutritional requirements regarding milk and milk products. Caloric intake needs to increase by 300 kcal per day during pregnancy to meet increased metabolic needs. However, “I’m eating for two” is a common misconception and leads to caloric intake greater than necessary. Caloric intake needs to increase by 300 kcal per day and should not be limited during pregnancy. Nutritional snacks throughout the day can provide for steady blood glucose levels and decrease the nausea associated with pregnancy. A limit of only three meals per day may not provide the client with enough calories to meet increased metabolic needs or may cause the client to eat more at each meal and increase nausea and bloating.
The nurse is caring for the pregnant client at the initial prenatal visit. Which universal screenings should the nurse complete? Select all that apply.
- A. Taking the client’s blood pressure
- B. Doing a urine dipstick test for protein
- C. Doing a urine dipstick test for glucose
- D. Asking questions about domestic violence
- E. Asking questions about use of tobacco
Correct Answer: A,D,E
Rationale: BP screening should be performed at the initial prenatal visit to establish a baseline and to evaluate for actual or potential problems. Domestic violence screening should be performed at the initial prenatal visit to determine fetal and maternal risk for harm. Screening for tobacco use should be performed at the initial prenatal visit to determine fetal and maternal risk. Smoking is associated with an increased risk for spontaneous abortion, preterm labor, and low birth weight. The use of routine urine dip assessments is unreliable in detecting proteinuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for a UTI. The urine dipstick test is of insufficient sensitivity to be used as a screening tool for glycosuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for the presence of glucose.