Nokea
The nurse’s assessment findings of the pregnant client include darkening of areola and nipple, presence of Goodell’s sign, leukorrhea, HR 124 bpm, dysuria, and heartburn. Of these findings, how many require further evaluation?
- A. 3
Correct Answer: 3
Rationale: There are three abnormal findings that require further evaluation. Leukorrhea needs to be distinguished from a vaginal infection, such as Candida albicans or a sexually transmitted infection. Heart rate can increase by 10 to 15 bpm during pregnancy, but an increase to 124 bpm is too high. Dysuria may be a sign of a UTI. Darkening of the areola and nipple, Goodell’s sign, and heartburn are normal findings during pregnancy and do not require further evaluation.
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The nurse assesses the 34-week pregnant client (G2P1). Place the assessment findings in the sequence that they should be addressed by the nurse from the most significant to the least significant.
- A. Pedal edema at +3
- B. BP 144/94 mm Hg
- C. Positive group beta streptococcus vaginal culture
- D. Fundal height increase of 4.5 cm in 1 week
Correct Answer: B,D,A,C
Rationale: BP 144/94 mm Hg warrants immediate evaluation. It could indicate preeclampsia, a condition that can progress to serious complications. Fundal height increase of 4.5 cm in 1 week is abnormal and requires further follow-up. Normal fundal height increase is 1 to 2 cm per week. An increase in fundal size can be related to gestational diabetes, large-for-gestational-age fetus, fetal anomalies, or polyhydramnios. Pedal edema at +3 may be a normal physiological process if it is an isolated finding. Pedal edema warrants further assessment because it can be a symptom of preeclampsia. Positive group beta streptococcus vaginal culture warrants antibiotic treatment in labor but does not warrant intervention during the pregnancy.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
Which statement by the client indicates a need for additional teaching regarding chlamydial infection?
- A. My sex partner(s) will require treatment as well.
- B. I will have to have a cesarean birth to protect my baby.
- C. The physician will treat the infection with an antibiotic.
- D. My Pap smear results may show abnormal cells.
Correct Answer: B
Rationale: Chlamydia does not typically require a cesarean birth; antibiotics treat the infection, and partners need treatment to prevent reinfection.
Which item should the client include in her hospital bag?
- A. Comfortable loose clothing
- B. High-heeled shoes
- C. Heavy perfumes
- D. Large meals
Correct Answer: A
Rationale: Comfortable loose clothing is practical for labor and postpartum, ensuring ease and comfort.
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.