Nokea
When caring for a woman whom a nurse suspects is being abused by her partner, the nurse should do which of the following?
- A. Ask the client directly about how she sustained her injuries.
- B. Counsel the client on how her behavior probably provoked the attack.
- C. Inform the client that the police must arrest her partner.
- D. Give the client a pamphlet with the names of matrimonial attorneys.
Correct Answer: A
Rationale: Directly asking about injuries helps assess the situation and provide appropriate support and resources.
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Which laboratory is important to know when a client is having an amniocentesis?
- A. Blood type
- B. CBC
- C. Rh
- D. PT and PTT
Correct Answer: C
Rationale: Step-by-step rationale:
1. Rh factor is crucial to know to prevent Rh incompatibility issues during pregnancy.
2. Amniocentesis can pose a risk for Rh sensitization in Rh-negative mothers.
3. Knowing the Rh status helps determine if Rhogam (anti-D) is needed after amniocentesis.
4. Blood type (A) and CBC (B) are important but not directly relevant to amniocentesis.
5. PT and PTT (D) are coagulation tests, typically not required for routine amniocentesis.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks' gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: The correct answer is B. An L/S ratio of 2:1 is indicative of fetal lung maturity. This means that the lungs of the fetus are likely mature enough to function outside the womb. In choice B, the patient is 24 years old with diabetes, a condition that can affect fetal lung development, making it crucial to assess lung maturity.
Choice A is less likely to have abnormal lung maturity at 38 weeks' gestation. Choice C, a 44-year-old gravida 6, para 5, is more likely to have mature fetal lungs due to multiple pregnancies. Choice D, an 18-year-old in early labor at term, may not necessarily have abnormal lung maturity as she is at term and in labor.
You are performing assessments for an obstetric patient who is 5 months pregnant with her third child. Which finding would cause you to suspect that the patient was at risk?
- A. Patient states that she doesn't feel any Braxton Hicks contractions like she had in her prior pregnancies.
- B. Fundal height is below the umbilicus.
- C. Cervical changes, such as Goodell's sign and Chadwick's sign, are present.
- D. She has increased vaginal secretions.
Correct Answer: B
Rationale: The correct answer is B: Fundal height is below the umbilicus. At 5 months pregnant with her third child, fundal height should be at or above the level of the umbilicus. A fundal height below the umbilicus may indicate intrauterine growth restriction or other fetal growth issues. This finding suggests a potential risk to the pregnancy's progress.
Incorrect Choices:
A: Patient not feeling Braxton Hicks contractions is common and not necessarily indicative of risk.
C: Presence of cervical changes like Goodell's and Chadwick's signs are expected physiological changes in pregnancy and do not necessarily indicate risk.
D: Increased vaginal secretions can be normal during pregnancy and do not necessarily signify a risk.
A client, who is 6 hours post–vaginal delivery, has a BP of 150/110. Her last 4 BP readings were: 114/88, 120/80, 134/86, 140/90. Which of the following questions should the nurse ask the client at this time?
- A. Have you had a bowel movement since delivery?'
- B. Is there anything that is making you anxious about the baby?'
- C. When you last went to the bathroom were you bleeding heavily?'
- D. Do you have a headache or blurring of your vision?'
Correct Answer: D
Rationale: Headache or blurring of vision could indicate postpartum preeclampsia, a serious condition requiring immediate intervention.
The nurse has identified the following nursing diagnosis for a postpartum (PP) client: Potential for fluid volume deficit. Which of the following goals for the mother is appropriate?
- A. Minimal perineal pain.
- B. Normal lochial flow.
- C. Normal temperature.
- D. Weight reduction.
Correct Answer: B
Rationale: Normal lochial flow indicates that the client is not experiencing excessive bleeding, which is a key concern for fluid volume deficit.