Nokea
When the nurse discusses the tasks to be accomplished during the client's visit at 24 weeks' gestation, which routine test will be performed?
- A. Coombs' test
- B. Glucose tolerance test
- C. Urinalysis
- D. Rubella titer
Correct Answer: B
Rationale: The glucose tolerance test is routinely performed around 24-28 weeks to screen for gestational diabetes.
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The nurse correctly explains to the group that the most important condition related to frequent urination during pregnancy is related to what factor?
- A. Loss of bladder tone in the mother
- B. The presence of a urinary tract infection
- C. The enlarging uterus exerting pressure on the bladder
- D. The growing fetus excreting increased amounts of waste
Correct Answer: C
Rationale: The enlarging uterus presses on the bladder, causing frequent urination, especially in early and late pregnancy.
The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?
- A. Call the HCP to report the pain
- B. Closely reinspect the perineum
- C. Help her out of bed to ambulate
- D. Administer a stool softener
Correct Answer: B
Rationale: Reexamination of the perineum should be completed before calling the HCP to report the pain level. A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass. Ambulation would not help the perineal pain. A stool softener would be appropriate to avoid constipation but would not help the immediate problem.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The nurse advises the client to clean the newborn's umbilical cord with which substance?
- A. Alcohol or antiseptic as prescribed
- B. Soap and water
- C. Hydrogen peroxide
- D. No cleaning needed
Correct Answer: A
Rationale: Cleaning with alcohol or antiseptic as prescribed prevents infection until the cord stump falls off.
The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?
- A. Black beans, wild rice, collard greens
- B. Dry cereal, milk, dried cranberries
- C. Tuna, broccoli, baked potato
- D. Beef strips, lentils, red peppers
Correct Answer: C
Rationale: Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.