Nokea
The nurse would be concerned that a 26-week-gravid client is carrying an unwanted pregnancy when the client makes which of the following statements?
- A. The baby hasn't started to move yet.'
- B. My back aches every night when I get home from work.'
- C. I am finding it very hard always to eat the right things.'
- D. I am no longer able to wear my old clothes.'
Correct Answer: A
Rationale: Lack of fetal movement at 26 weeks could indicate a problem with the pregnancy or that the client is not emotionally connected to the pregnancy, suggesting it may be unwanted.
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A 32-week-gravid client presents in the emergency department with severe abdominal pain, rigid abdomen, and scant dark red bleeding. The nurse should assess this client for which of the following?
- A. Signs of pulmonary edema.
- B. Enlarging abdominal girth measurements.
- C. Hyporeflexia and confusion.
- D. Signs of diabetic coma and ketosis.
Correct Answer: B
Rationale: Severe abdominal pain, rigidity, and dark red bleeding could indicate placental abruption, which may cause enlarging abdominal girth due to internal bleeding.
The nurse in the obstetrician’s office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor?
- A. African American, 15 years old, with newly diagnosed gestational diabetes.
- B. Asian American, 23 years old, with five-year-old twins who were born at term.
- C. Jewish, 25 years old, working as a certified public accountant.
- D. Mormon, 33 years old, who recently moved into a new apartment.
Correct Answer: A
Rationale: Young age and gestational diabetes are risk factors for preterm labor, making it important to educate this client.
A doula is working with a laboring woman who is 6 cm dilated and is contracting every 3 min × 60 sec on an oxytocin drip. Which of the following interventions should the nurse suggest the doula perform?
- A. Regulate the oxytocin drip rate.
- B. Check the vaginal dilation of the client.
- C. Encourage the woman to use breathing techniques.
- D. Monitor the client for uterine hyperstimulation.
Correct Answer: C
Rationale: The doula's role is to provide emotional and physical support, such as encouraging breathing techniques. Regulating medications and monitoring for complications are the nurse's responsibilities.
A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a nutritious diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate in the hallways every shift.
Correct Answer: C
Rationale: Ensuring the client has a moderate lochial flow is a priority to monitor for postpartum hemorrhage.
A client complaining of frequency, urgency, and burning on urination is seen by her health care practitioner. Which of the following factors in the client's history places her at risk for these complaints?
- A. The client urinates immediately after every sexual encounter.
- B. The client uses the diaphragm as a family planning method.
- C. The client wipes from front to back after every toileting.
- D. The client changes her peripads every two hours during her menses.
Correct Answer: B
Rationale: The use of a diaphragm can increase the risk of urinary tract infections due to pressure on the urethra.