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When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, which of the following would the nurse expect to include as a desired target range for blood glucose levels?
- A. 40 to 60 mg/dL between 2:00 and 4:00 p.m.
- B. 60 to 100 mg/dL before meals and bedtime snacks.
- C. 110 to 140 mg/dL before meals and bedtime snacks.
- D. 140 to 160 mg/dL 1 hour after meals.
Correct Answer: B
Rationale: Target range before meals and bedtime snacks is 60-100 mg/dL.
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The nurse is assessing a multiparous client 12 hours after vaginal delivery. Which finding requires immediate intervention?
- A. Fundus firm, 1 cm above umbilicus.
- B. Lochia rubra with small clots.
- C. Perineal pain rated 3/10.
- D. Pulse 100 bpm, temperature 100.4°F (38°C).
Correct Answer: D
Rationale: An elevated pulse and temperature may indicate infection or hemorrhage, requiring prompt intervention.
To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures?
- A. Sagittal.
- B. Lambdoidal.
- C. Coronal.
- D. Frontal.
Correct Answer: A
Rationale: In the LOA position, the fetus's occiput is anterior, and the sagittal suture (running midline along the skull) is most accessible during vaginal examination to assess dilation and fetal position. Other sutures are less prominent in this presentation.
Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
- A. Decreased generalized edema within 8 hours.
- B. Decreased urinary output during the first 24 hours.
- C. Sedation and decreased reflex excitability within 48 hours.
- D. Absence of any seizure activity during the first 48 hours.
Correct Answer: D
Rationale: Preventing seizures is the priority in managing severe preeclampsia.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
- A. A client at 13 weeks' gestation experiencing nausea and vomiting three times a day with +1 ketones in her urine.
- B. A client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day.
- C. A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.
- D. A primigravida at 17 weeks' gestation complaining of not feeling fetal movement at this point in her pregnancy.
Correct Answer: C
Rationale: Epigastric pain in a preeclamptic client can indicate impending eclampsia.