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Which finding during a prenatal visit is most concerning in a client at 32 weeks gestation?
- A. Blood pressure of 120/80 mmHg
- B. Mild lower back pain
- C. Weight gain of 2 pounds in one week
- D. Proteinuria of +2 on a urine dipstick
Correct Answer: D
Rationale: Proteinuria is a potential sign of preeclampsia, requiring evaluation.
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The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.
The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?
- A. Assess for bladder distention.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check for pain relief.
Correct Answer: B
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension, a common side effect of epidural anesthesia.
What is the second stage of pathophysiology in an on anticoagulant therapy due to a deep vein throm- amniotic fluid embolism characterized by? bosis, which occurred after giving birth. Which of
- A. Hemorrhage the following instructions should the nurse include?
- B. Hypoxia
- C. Take an herbal supplement such as St. John's wort
- D. Capillary damage to help increase the effect of the anticoagulant.
Correct Answer: A
Rationale: The second stage of pathophysiology in an amniotic fluid embolism characterized by deep vein thrombosis on anticoagulant therapy after giving birth involves the risk of hemorrhage. Anticoagulant therapies such as heparin increase the risk of bleeding since they inhibit the blood's ability to clot effectively. This means that in the event of an injury or surgery, there is a higher likelihood of excessive bleeding. Therefore, it is crucial to monitor for signs of hemorrhage such as bruising, bleeding gums, blood in urine or stool, and low blood pressure. Intervention to manage bleeding may include reducing the dosage of the anticoagulant, administering blood products, and implementing pressure or surgical interventions as necessary.
The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
A patient at 24 weeks of gestation reports that she has a glass of wine with dinner every evening. Which rationale should the nurse provide this patient regarding the necessity to eliminate alcohol intake? N R I G B.C M U S N T O
- A. The fetus is placed at risk for altered brain growth.
- B. The fetus is at risk for severe nervous system injury.
- C. The patient will be at risk for abusing other substances as well.
- D. A daily consumption of alcohol indicates a risk for alcoholism.
Correct Answer: A
Rationale: The correct rationale that the nurse should provide to the patient regarding the necessity to eliminate alcohol intake during pregnancy is that the fetus is placed at risk for altered brain growth. Alcohol consumption during pregnancy can lead to a condition known as Fetal Alcohol Syndrome (FAS), which is characterized by various physical and intellectual disabilities in the child. One of the major consequences of alcohol exposure during pregnancy is impaired brain development in the fetus. This can result in cognitive, behavioral, and neurological problems that may persist throughout the child's life. Therefore, it is crucial for pregnant women to completely abstain from alcohol to protect the health and well-being of the developing fetus.