Nokea
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: The correct answer is C: Urine output >100 mL/hour. This signifies improved kidney function, a key indicator of recovery in preeclampsia. Increased urine output indicates better kidney perfusion and reduced risk of complications like renal failure. A: 1+ protein in urine suggests ongoing kidney damage. B: 2+ pitting edema in lower extremities indicates fluid retention, a common symptom of preeclampsia. D: Deep tendon reflexes +2 are not specific to preeclampsia recovery, although hyperreflexia can be seen in severe cases.
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A pregnant client with a history of preterm labor is at home on bed rest. Which instruction would be included in this client's teaching plan?
- A. Place blocks under the foot of the bed.
- B. Sit upright with several pillows behind the back.
- C. Lie on the side with the head raised on a small pillow.
- D. Assume the knee-chest position at regular intervals throughout the day.
Correct Answer: C
Rationale: The correct answer is C: Lie on the side with the head raised on a small pillow. This position helps improve circulation to the uterus and placenta, reducing the risk of preterm labor. Lying on the left side also promotes optimal blood flow. Option A is incorrect as elevating the foot of the bed can decrease blood flow to the placenta. Option B may cause discomfort and increase pressure on the cervix. Option D is not suitable for bed rest as it involves being on all fours, which is not conducive to rest and relaxation.
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
- A. immediate birth is required.
- B. the patient should be transferred to the critical care unit for closer observation.
- C. RhoGAM should be administered.
- D. a tetanus shot should be administered.
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The positive Kleihauer–Betke test indicates fetal-maternal hemorrhage, where fetal blood enters the maternal circulation. This can lead to fetal-maternal transfusion, causing fetal anemia. Immediate birth is necessary to assess and manage potential fetal distress, such as anemia and hypoxia, due to the trauma from the MVA.
Choices B, C, and D are incorrect:
B: Transferring to critical care unit is not the immediate priority. The focus should be on addressing the fetal distress.
C: RhoGAM is given to Rh-negative mothers to prevent Rh sensitization, but it is not directly related to the positive Kleihauer–Betke test result.
D: Tetanus shot administration is important for tetanus prevention, but it is not the priority in this case where immediate birth is required due to fetal-maternal hemorrhage.
Which disease process improves during pregnancy?
- A. Epilepsy
- B. Bell's palsy
- C. Rheumatoid arthritis
- D. Systemic lupus erythematosus (SLE)
Correct Answer: C
Rationale: Pregnancy often leads to an improvement in rheumatoid arthritis due to the immunosuppressive state that occurs to prevent rejection of the fetus. This reduction in immune activity can alleviate symptoms of rheumatoid arthritis. On the other hand, epilepsy, Bell's palsy, and SLE do not typically improve during pregnancy and may even worsen due to hormonal changes and stress on the body. Epilepsy can be challenging to manage during pregnancy, as seizures can potentially harm both the mother and the fetus. Bell's palsy may not improve and could be exacerbated by hormonal changes. SLE is a chronic autoimmune disease that can be unpredictable during pregnancy, with potential flares and complications for both the mother and the fetus.
Anti-infective prophylaxis is indicated for a pregnant patient with a history of mitral valve stenosis related to rheumatic heart disease because the patient is at risk of developing
- A. hypertension.
- B. postpartum infection.
- C. bacterial endocarditis.
- D. upper respiratory infections.
Correct Answer: C
Rationale: The correct answer is C: bacterial endocarditis. Pregnant patients with mitral valve stenosis are at increased risk for developing bacterial endocarditis due to the presence of abnormal valve structures. This condition can lead to serious complications including septic emboli and heart failure. Hypertension (choice A) is not directly related to mitral valve stenosis. Postpartum infection (choice B) is not a primary concern in this scenario. Upper respiratory infections (choice D) are not specifically associated with mitral valve stenosis. In summary, anti-infective prophylaxis is indicated to prevent bacterial endocarditis in pregnant patients with a history of mitral valve stenosis.
Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: The correct answer is C: 3. A score of 3 in edema assessment indicates significant edema in the lower extremities, face, hands, and sacral area. This score reflects a higher level of pitting edema, which is commonly observed in these areas in cases of fluid retention. Scores 1 and 2 are typically used to indicate mild to moderate edema in specific areas or generalized mild edema, not as extensive as described in the question. Score 4 would typically indicate severe edema involving not only the mentioned areas but also potentially other body parts. Therefore, choice C is the most appropriate answer based on the extent and distribution of edema described in the question.