Nokea
Which instructions should the nurse include when teaching a pregnant patient with Class II heart disease?
- A. Advise her to gain at least 30 lb.
- B. Instruct her to avoid strenuous activity.
- C. Inform her of the need to limit fluid intake.
- D. Explain the importance of a diet high in calcium.
Correct Answer: B
Rationale: The correct answer is B: Instruct her to avoid strenuous activity. For a pregnant patient with Class II heart disease, avoiding strenuous activity is crucial to prevent excessive strain on the heart. Strenuous activities can lead to increased heart rate and blood pressure, which can worsen the heart condition. Advising her to gain at least 30 lb (choice A) may put additional strain on the heart. Limiting fluid intake (choice C) can lead to dehydration, affecting blood volume and circulation. A diet high in calcium (choice D) is beneficial for overall health but is not specifically related to managing Class II heart disease during pregnancy.
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What virus is highly contagious, spread through airborne particles, and can cause intrauterine fetal demise, skin scarring, eye, limb or neurologic abnormalities, anemia, thrombocytopenia, and low birth weight in the fetus?
- A. toxoplasmosis
- B. syphilis
- C. rubella
- D. Varicella (chickenpox)
Correct Answer: D
Rationale: The correct answer is D: Varicella (chickenpox). Varicella virus is highly contagious and spreads through airborne particles. It can cause intrauterine fetal demise, skin scarring, eye, limb, or neurologic abnormalities, anemia, thrombocytopenia, and low birth weight in the fetus. Varicella infection during pregnancy can lead to severe complications for both the mother and the fetus. Toxoplasmosis (A), syphilis (B), and rubella (C) can also cause complications during pregnancy, but they do not match all the characteristics mentioned in the question.
A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
- A. “I know I will need to have an abortion as soon as possible.”
- B. “Even though my test is positive, my baby might not be affected.”
- C. “My baby is certain to have AIDS and die within the first year of life.”
- D. “This pregnancy will probably decrease the chance that I will develop AIDS.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that a positive HIV test in the mother doesn't guarantee transmission to the baby. This reflects knowledge of the possibility of preventing mother-to-child transmission with proper medical care. Option A is incorrect as abortion is not the standard recommendation for HIV-positive pregnant women. Option C is incorrect as not all babies born to HIV-positive mothers will have AIDS or die within the first year. Option D is incorrect as pregnancy does not decrease the mother's chance of developing AIDS.
An abortion when the fetus dies but is retained in the uterus is called
- A. inevitable.
- B. missed.
- C. incomplete.
- D. threatened.
Correct Answer: B
Rationale: The correct answer is B: missed. In a missed abortion, the fetus dies but is not expelled from the uterus. This can be diagnosed during an ultrasound when no fetal heartbeat is detected. The term "inevitable" (choice A) refers to an abortion that is in progress and cannot be stopped. "Incomplete" (choice C) refers to an abortion where some fetal or placental tissue remains in the uterus. "Threatened" (choice D) refers to vaginal bleeding in early pregnancy, with a viable pregnancy.
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse"™s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient when she last had anything to eat or drink. This is the correct action because the patient is in active labor with genital herpes lesions. Knowing the last time the patient had anything to eat or drink is essential in case an emergency cesarean section is needed, as the patient may need to be NPO.
Option B: Taking a culture of the lesions is not the immediate priority as the patient is in active labor and the presence of lesions is already confirmed.
Option C: Asking about unprotected sex is important for history taking but not the immediate next action in this scenario.
Option D: Using electronic fetal surveillance is also important, but the priority in this case is assessing the patient's fasting status for potential emergency procedures.
Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
- A. Urine output of 30 mL in 1 hour
- B. Blood pressure of 110/60 mm Hg
- C. Bleeding at IV insertion site
- D. Respiratory rate of 16 breaths per minute
Correct Answer: C
Rationale: The correct answer is C because bleeding at the IV insertion site could indicate disseminated intravascular coagulation (DIC), a major complication of placental abruption. DIC is a serious condition that results in widespread clotting and bleeding throughout the body. This finding signifies that the patient's clotting factors are being consumed rapidly, leading to uncontrolled bleeding. Options A, B, and D are not indicative of a major complication of placental abruption. A decreased urine output, low blood pressure, and normal respiratory rate may be seen in various conditions but are not specific to DIC or a major complication in this context.