Nokea
History and Physical:
Laboratory Results:
The client is a 24-year-old pregnant woman. She is gravida 2, para 1 (G2P1). Her mother has a history of type 2 diabetes mellitus.
Which is likely causing this client's increased blood glucose at 28 weeks? Select all that is apply.
- A. Fetal health problems
- B. Decreased cortisol
- C. Increased insulin needs
- D. Placental infection
- E. Normal weight gain of pregnancy
- F. Fetus with macrosomia
Correct Answer: C,E,F
Rationale: Increased insulin needs, normal weight gain, and macrosomia contribute to insulin resistance and hyperglycemia in pregnancy, unlike fetal health issues, decreased cortisol, or placental infection.
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The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?
- A. Improve insufficient dietary intake.
- B. Stimulate the immune system.
- C. Prevent hemorrhagic disorders.
- D. Help an immature liver.
Correct Answer: C
Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.
Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mm Hg and her heart rate is 130 beats/minute. Which action should the nurse implement first?
- A. Obtain a blood sample for complete blood count.
- B. Infuse 1,000 mL normal saline using a large bore intravenous (IV) catheter.
- C. Palpate the abdomen for contractions.
- D. Tilt the backboard sideways to displace the uterus laterally.
Correct Answer: D
Rationale: Tilting the backboard relieves uterine compression on the inferior vena cava, addressing supine hypotension syndrome, which is critical to improve maternal blood pressure and fetal perfusion.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.
A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
- A. Intensity of pain with contraction.
- B. Fetal heart rate.
- C. Temperature, pulse, and respirations.
- D. Deep tendon reflexes and clonus.
Correct Answer: D
Rationale: Assessing deep tendon reflexes and clonus detects CNS irritability, critical for identifying severe preeclampsia and eclampsia risk.
The day shift nurse reviews the nurse's notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge health teaching. For each teaching point, indicate whether it is Indicated (appropriate or necessary) or Contraindicated (could be harmful). Each box must have one option selected.
- A. You will need to set up an appointment with your pediatrician for 3 weeks from discharge.
- B. The discharge planning nurse will set up home bilirubin lights for you to use until you see the pediatrician.
- C. You will need to set up an appointment with your obstetrician in 8 weeks.
Correct Answer: A,B,C
Rationale: A: Indicated - Pediatric check-ups at 2-4 weeks monitor newborn health. B: Indicated - Bilirubin lights treat jaundice, preventing complications. C: Contraindicated - Obstetrician visits are typically at 6 weeks, not 8.