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Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: The correct answer is C: 3. A score of 3 in edema assessment indicates significant edema in the lower extremities, face, hands, and sacral area. This score reflects a higher level of pitting edema, which is commonly observed in these areas in cases of fluid retention. Scores 1 and 2 are typically used to indicate mild to moderate edema in specific areas or generalized mild edema, not as extensive as described in the question. Score 4 would typically indicate severe edema involving not only the mentioned areas but also potentially other body parts. Therefore, choice C is the most appropriate answer based on the extent and distribution of edema described in the question.
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Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?
- A. Determining cervical dilation and effacement
- B. Monitoring FHR and maternal vital signs
- C. Observing vaginal bleeding or leakage of amniotic fluid
- D. Determining frequency, duration, and intensity of contractions
Correct Answer: A
Rationale: The correct answer is A: Determining cervical dilation and effacement. This assessment is contraindicated for a patient with suspected placenta previa because it can lead to further disruption of the placenta and potentially cause severe bleeding. Monitoring FHR and vital signs (B) is important for assessing fetal well-being and maternal status. Observing vaginal bleeding or amniotic fluid leakage (C) is crucial in identifying complications. Determining the frequency, duration, and intensity of contractions (D) is essential for monitoring labor progression but is not appropriate for a patient with suspected placenta previa due to the risk of placental disruption.
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: The correct answer is C: Urine output >100 mL/hour. This signifies improved kidney function, a key indicator of recovery in preeclampsia. Increased urine output indicates better kidney perfusion and reduced risk of complications like renal failure. A: 1+ protein in urine suggests ongoing kidney damage. B: 2+ pitting edema in lower extremities indicates fluid retention, a common symptom of preeclampsia. D: Deep tendon reflexes +2 are not specific to preeclampsia recovery, although hyperreflexia can be seen in severe cases.
Rh incompatibility can occur if the patient is Rh-negative and the
- A. fetus is Rh-negative.
- B. fetus is Rh-positive.
- C. father is Rh-positive.
- D. father and fetus are both Rh-negative.
Correct Answer: B
Rationale: The correct answer is B because Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. During pregnancy or birth, some fetal Rh-positive blood may enter the mother's bloodstream, leading to the production of Rh antibodies. These antibodies can then cause complications in future pregnancies if the fetus is Rh-positive again. Choices A, C, and D are incorrect because Rh incompatibility specifically involves the Rh factor of the fetus, not the mother's own Rh status, the father's Rh status, or both being Rh-negative.
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?
- A. Saturated perineal pad in 1 hour
- B. Pain level 0 on a scale of 0 to 10
- C. Cervical dilation at 2 cm
- D. Fetal heart rate at 160 bpm
Correct Answer: B
Rationale: The correct answer is B because in placenta previa, pain is usually minimal or absent, while in abruptio placentae, there is severe abdominal pain. Saturated perineal pad (choice A) is common in both conditions. Cervical dilation (choice C) is not specific to differentiate between the two conditions. Fetal heart rate (choice D) may be normal in both conditions.
Which disease process improves during pregnancy?
- A. Epilepsy
- B. Bell's palsy
- C. Rheumatoid arthritis
- D. Systemic lupus erythematosus (SLE)
Correct Answer: C
Rationale: Pregnancy often leads to an improvement in rheumatoid arthritis due to the immunosuppressive state that occurs to prevent rejection of the fetus. This reduction in immune activity can alleviate symptoms of rheumatoid arthritis. On the other hand, epilepsy, Bell's palsy, and SLE do not typically improve during pregnancy and may even worsen due to hormonal changes and stress on the body. Epilepsy can be challenging to manage during pregnancy, as seizures can potentially harm both the mother and the fetus. Bell's palsy may not improve and could be exacerbated by hormonal changes. SLE is a chronic autoimmune disease that can be unpredictable during pregnancy, with potential flares and complications for both the mother and the fetus.