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A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.
Which of the following discomforts should the nurse include in the teaching?
- A. Tingling in the fingers.
- B. Round ligament pain.
- C. Urinary urgency and frequency.
- D. Perineal itching and pressure.
Correct Answer: C
Rationale: Urinary urgency and frequency are common in the first trimester due to hormonal changes and increased pelvic blood flow, pressing on the bladder.
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A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Tachypnea.
- B. Hyporeflexia.
- C. Agitation.
- D. Polyuria.
Correct Answer: B
Rationale: Hyporeflexia indicates magnesium sulfate toxicity, a serious adverse effect requiring immediate reporting to prevent respiratory or cardiac issues.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.
Nurses' Notes: The client, who is 28 weeks gestation, gravida 4, para 3, reports a history of vaginal bleeding for the past 2 hours. She states, 'I started bleeding a couple of hours ago, but now I am saturating pads with bright red blood. I’m scared something is going to happen to my baby.' Blood is trickling down her legs. She denies abdominal pain. A perineal pad is saturated with bright red vaginal bleeding. Physical Examination Results: Fundal height is 27 cm. No uterine contractions or irritability. Fetal heart rate: 170/min, minimal variability, no decelerations. Diagnostic Results: Urine: Leukocyte esterase positive, Nitrites positive, Red blood cells: 6.
Complete the diagram by dragging from the choices below to specify: Potential Condition, Actions to Take (Select 2), Parameters to Monitor (Select 2). Potential Condition Choices: A. Placenta previa, B. Abruptio placentae, C. Preterm labor, D. Uterine rupture. Actions: A. Administer methotrexate, B. Administer broad-spectrum antibiotics, C. Prepare for an emergency cesarean birth, D. Reinforce bed rest and maintain IV access, E. Encourage ambulation. Parameters: A. Fetal heart rate, B. Maternal oxygen saturation, C. WBC count, D. Urine output, E. Uterine contractions.
- A. Placenta previa
- B. Prepare for an emergency cesarean birth
- C. Reinforce bed rest and maintain IV access
- D. Fetal heart rate
- E. Maternal oxygen saturation
Correct Answer: A,C,D,A,B
Rationale: Painless bleeding suggests placenta previa; cesarean and bed rest manage it; fetal heart rate and oxygen saturation monitor stability.
A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
- A. Image showing toes fanning out when the sole is stroked.
- B. Image showing the newborn grasping a finger when the palm is touched.
- C. Image showing the newborn turning the head when the cheek is stroked.
- D. Image showing the newborn making stepping movements when held upright.
Correct Answer: A
Rationale: The image showing toes fanning out when the sole of the foot is stroked demonstrates a positive Babinski reflex, a normal newborn response indicating immature nervous system development.
A nurse is reinforcing teaching with a client about laboratory testing during pregnancy.
Which of the following statements should the nurse include in the teaching?
- A. A multiple marker screening will be performed to identify neural tube defects.
- B. A glucose tolerance test will be performed to predict hyperglycemia in your baby.
- C. A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- D. A group B streptococcus screening will be performed to determine the presence of STIs.
Correct Answer: A
Rationale: A multiple marker screening detects neural tube defects and chromosomal abnormalities, typically performed between 15-20 weeks of gestation.