Nokea
When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
- A. Ambivalence
- B. Emotional lability
- C. Introversion
- D. Acceptance
Correct Answer: B
Rationale: Emotional lability is typical in the first trimester from hormonal changes causing irritability or crying. Ambivalence is less common unless conflicted, introversion isn't pregnancy-specific, and acceptance grows over time.
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A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.
- A. Nausea
- B. Abdominal enlargement
- C. Positive pregnancy test
- D. Braxton Hicks contractions
- E. Amenorrhea
Correct Answer: A,B,C,E
Rationale: Presumptive signs, subjective or non-definitive, include nausea (hormonal), abdominal enlargement (uterine growth), positive pregnancy test (hCG detection), and amenorrhea (missed periods). Braxton Hicks are probable signs, felt later.
It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
- A. 24 hours before delivery and 24 hours after delivery
- B. In the first trimester and within 2 hours of delivery
- C. At 28 weeks gestation and again within 72 hours after delivery
- D. At 32 weeks gestation and immediately before discharge
Correct Answer: C
Rationale: Rho(D) immune globulin at 28 weeks and within 72 hours post-delivery prevents Rh isoimmunization effectively. Other schedules miss critical windows for blocking maternal antibody response.
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.
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?
- A. Hemorrhage
- B. Edema
- C. Infection
- D. Jaundice
Correct Answer: A
Rationale: A ruptured ectopic pregnancy causes internal bleeding, leading to hypovolemic shock, making hemorrhage the priority assessment. Edema, infection, or jaundice may occur later but are less urgent than life-threatening bleeding.
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.