Nokea
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
- A. I'm sorry you lost your baby.
- B. Why are you crying?
- C. Will a pill help your pain?
- D. A baby still wasn't formed in your womb.
Correct Answer: A
Rationale: Saying 'I'm sorry you lost your baby' acknowledges the client's emotional loss empathetically. Asking why she's crying invalidates her feelings, focusing on physical pain ignores emotional needs, and claiming the baby wasn't formed is inaccurate and insensitive, as miscarriage involves loss at any stage.
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A nurse is providing prenatal care to a pregnant client. At which time would the nurse expect to screen the client for group B streptococcus infection?
- A. 28 weeks' gestation
- B. 32 weeks' gestation
- C. 16 weeks' gestation
- D. 36 weeks' gestation
Correct Answer: D
Rationale: Screening for group B streptococcus (GBS) is done at 35-37 weeks (36 weeks is closest) to assess colonization status near delivery, guiding intrapartum antibiotic use to prevent neonatal infection. Earlier screening (16, 28, or 32 weeks) may not reflect status at birth, as GBS colonization can change.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?
- A. Vitamin E requirements decrease during pregnancy due to the increase in body fat.
- B. Prenatal vitamins will meet your need for increased folic acid during pregnancy.
- C. You will need to double your intake of protein during pregnancy.
- D. You will need to increase your intake of calcium during pregnancy.
Correct Answer: B
Rationale: Prenatal vitamins provide 600 mcg/day folic acid, meeting pregnancy needs to prevent neural tube defects. Vitamin E needs remain at 15 mg/day, protein increases slightly to 1.1 g/kg/day (not doubled), and calcium needs stay at 1000 mg/day due to enhanced absorption, not requiring an increase.
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?
- A. striae gravidarum
- B. linea nigra
- C. vascular spiders
- D. melasma
Correct Answer: B
Rationale: Linea nigra is a dark line from umbilicus to pubis caused by increased melanin from hormonal changes. Striae gravidarum are stretch marks, vascular spiders are dilated vessels on face or chest, and melasma is facial pigmentation, none matching the abdominal line description.
A nurse is teaching a pregnant client in her first trimester about discomforts that she may experience. The nurse determines that the teaching was successful when the woman identifies which discomforts as common during the first trimester? Select all that apply.
- A. Breast tenderness
- B. Urinary frequency
- C. Backache
- D. Cravings
- E. Leg cramps
Correct Answer: A,B,D
Rationale: First trimester discomforts include breast tenderness (hormonal growth), urinary frequency (bladder pressure), and cravings (taste changes). Backache and leg cramps typically occur later due to weight and nerve pressure.
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
- A. Difficulty in arousing
- B. Deep tendon reflexes 2+
- C. Urinary output of 30 mL per hour
- D. Respiratory rate of 10 breaths/minute
Correct Answer: B
Rationale: Deep tendon reflexes at 2+ indicate a therapeutic magnesium level, preventing seizures without toxicity. Difficulty arousing, low urinary output (below 40 mL/hr), or respiratory rate of 10 suggest toxicity, requiring intervention.