Nokea
When caring for clients in a prenatal clinic, a nurse should report which client's weight gain to the provider?
- A. 1.8 kg (4 lb) weight gain in the first trimester
- B. 3.6 kg (8 lb) weight gain in the first trimester
- C. 6.8 kg (15 lb) weight gain in the second trimester
- D. 11.3 kg (25 lb) weight gain in the third trimester
Correct Answer: B
Rationale: The correct answer is B: 3.6 kg (8 lb) weight gain in the first trimester. This amount of weight gain in the first trimester is higher than the recommended range of 1.1-4.5 lbs. It could indicate potential issues such as gestational diabetes or preeclampsia. Choices A, C, and D fall within or closer to the expected weight gain ranges for each trimester, making them less concerning. Reporting excessive weight gain early allows for timely intervention and monitoring.
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A healthcare provider is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the provider expect? (Select all that apply)
- A. Chadwick's sign
- B. Goodell's sign
- C. Ballottement
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all three signs (Chadwick's sign, Goodell's sign, and Ballottement) are probable signs of pregnancy. Chadwick's sign refers to bluish discoloration of the cervix, Goodell's sign is softening of the cervix, and Ballottement is a palpable rebound of the fetus against the examiner's fingers. These signs are indicative of pregnancy and are commonly observed in pregnant individuals. Therefore, the provider should expect to see all these findings in a pregnant client. The other choices (A, B, and C) are incorrect because each of these signs individually is a probable sign of pregnancy, and the question asks for all the expected findings, not just one or two of them.
A client who is 2 hours postpartum is in the taking-hold phase. Which intervention should the nurse plan to implement during this phase of postpartum behavioral adjustment?
- A. Discuss contraceptive options with the client and her partner.
- B. Repeat information to ensure client understanding.
- C. Listen to the client and her partner as they reflect upon the birth experience.
- D. Demonstrate to the client how to perform a newborn bath.
Correct Answer: D
Rationale: The correct answer is D because during the taking-hold phase, the client is focused on learning and mastering new skills related to caring for the newborn. Demonstrating how to perform a newborn bath aligns with this phase as it helps the client gain confidence and competence in newborn care. Discussing contraceptive options (choice A) is more appropriate during the let-go phase. Repeating information (choice B) may be necessary but is not the priority during the taking-hold phase. Listening to the client and her partner reflect on the birth experience (choice C) is important for emotional support but not specifically related to the behavioral adjustments in the taking-hold phase.
When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
- A. Count the fetal heart rate for 15 seconds to determine the baseline.
- B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
- C. Count the fetal heart rate after a contraction to determine baseline changes.
- D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?
- A. Hgb 12.2 g/dL
- B. Urine ketones present
- C. Alanine aminotransferase 20 IU/L
- D. Blood glucose 114 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Urine ketones present. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy, leading to dehydration and ketonuria. Presence of urine ketones indicates fat breakdown due to inadequate calorie intake. Option A is within normal range for hemoglobin. Option C is within normal range for alanine aminotransferase. Option D is within normal range for blood glucose. Thus, the presence of urine ketones is the most indicative finding for hyperemesis gravidarum.
A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?
- A. Active
- B. Transition
- C. Latent
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase.
Summary:
A: Active phase occurs when the cervix is dilated from 4 to 7 cm.
C: Latent phase occurs when the cervix is dilated from 0 to 3 cm.
D: Descent phase is not a recognized phase of labor.