Nokea
The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.
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A client at 37 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Preeclampsia.
- B. Cholestasis of pregnancy.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: B
Rationale: The correct answer is B: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 37 weeks' gestation is concerning for cholestasis of pregnancy, a condition characterized by impaired bile flow. This can lead to elevated bile acids, causing itching. Preeclampsia (choice A) presents with hypertension and proteinuria. Gestational diabetes (choice C) manifests with high blood sugar levels. Fungal infection (choice D) typically presents with visible skin changes like a rash, which is absent in this case. In summary, cholestasis of pregnancy is the most likely explanation for severe itching in this scenario.
What is an advantage of the internal condom?
- A. It can be used by those who have a latex allergy.
- B. It can be used for repeated acts of intercourse.
- C. It has a lower failure rate than external condoms.
- D. It can be used for pleasure purposes.
Correct Answer: A
Rationale: The correct answer is A because the internal condom is made of nitrile, which is a non-latex material. This makes it suitable for individuals with latex allergies. Choice B is incorrect because both internal and external condoms can be used for repeated acts of intercourse. Choice C is incorrect because internal condoms do not necessarily have a lower failure rate than external condoms. Choice D is incorrect because while condoms can enhance pleasure during intercourse, the primary purpose of the internal condom is for protection rather than pleasure.
The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.
A nurse is reviewing the laboratory results for a client who is at 29 weeks.... the provider?
- A. WBC count
- B. 11,000/mm³ Hgb
- C. 11,2 g/Dl
- D. Hct 34% Platelets 140,000/mm³
Correct Answer: B
Rationale: The correct answer is B: 11,000/mm³ Hgb. At 29 weeks of gestation, hemoglobin (Hgb) levels are crucial to monitor for anemia in pregnant women. A Hgb level of 11,000/mm³ is within the normal range for a pregnant woman. Anemia during pregnancy can lead to adverse outcomes for both the mother and the baby, such as preterm birth and low birth weight.
Rationale for other choices:
A: WBC count - While monitoring white blood cell (WBC) counts is important for detecting infections, it is not the most relevant parameter to review in this scenario.
C: 11,2 g/Dl - This choice is incomplete and doesn't provide a specific parameter or context for interpretation.
D: Hct 34% Platelets 140,000/mm³ - Hematocrit (Hct) and platelet levels are important, but in this case, the Hgb level is more pertinent
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.