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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. Urination urgency and frequency.
- D. Perineal discomfort and pressure.
Correct Answer: C
Rationale: Urination urgency and frequency are common first-trimester discomforts due to hormonal changes and uterine pressure on the bladder.
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A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets.
- B. Weigh the newborn's wet diaper.
- C. Auscultate the newborn's bowel sounds.
- D. Determine the newborn's respiratory rate.
Correct Answer: D
Rationale: Determining the respiratory rate first ensures airway and breathing stability, a critical initial step in managing neonatal abstinence syndrome.
A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.
Which of the following actions should the nurse encourage the client to take?
- A. Eat dry, bland foods in the morning.
- B. Take an over-the-counter antacid.
- C. Increase intake of fresh fruits.
- D. Restrict fluids to 1,000 ml/day.
Correct Answer: A
Rationale: Eating dry, bland foods like crackers in the morning can alleviate nausea by absorbing stomach acid, a common remedy for early pregnancy nausea.
Nurses' Notes (Postpartum Assessment) 1200: The client successfully delivered a viable newborn via vaginal delivery. 1300: The client reports feeling tired and anxious. Assessment reveals the fundus is deviated to the left, boggy, and located 1 cm above the umbilicus. The perineal pad is saturated with lochia rubra, indicating excessive bleeding. The client reports an inability to ambulate to the bathroom due to residual numbness from the labor epidural. Pain is reported as 0 on a scale of 0 to 10. Fundal massage performed during assessment has yielded no improvement in uterine tone. A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation admitted for evaluation of postpartum bleeding following a vaginal delivery.
Select the 2 interventions the nurse should perform immediately.
- A. Weigh the client’s perineal pad.
- B. Insert a straight catheter for the client.
- C. Administer methylergonovine 0.2 mg IM.
- D. Draw a complete blood count.
- E. Apply oxygen via nasal cannula.
Correct Answer: B,C
Rationale: Inserting a catheter empties the bladder, aiding uterine contraction; methylergonovine stimulates contractions to reduce bleeding from a boggy uterus.
Nurses' Notes Two weeks ago (32 weeks gestation): The client presented for a routine visit and denied vaginal bleeding or fluid leakage. Reports mild insomnia and occasional mild uterine cramping. 1+ nonpitting edema noted in bilateral feet and ankles. Weight recorded as 84 kg (185 lb). Today (0930): The client reports mild epigastric pain for the past three days and occasionally 'seeing spots' in her vision. 2+ nonpitting edema noted bilaterally in feet and ankles, and mild facial edema present. The client states her fingers 'swelled up overnight,' preventing her from wearing rings. Weight has increased to 86 kg (190 lb). Vital Signs: Blood pressure: 160/100 mm Hg, Heart rate: 88/min, Respiratory rate: 18/min, Temperature: 36.9°C (98.4°F), Oxygen saturation: 98% on room air. Diagnostic Results: Hemoglobin: 10 g/dL, Hematocrit: 35.9%, Platelet count: 95,000/mm³, AST: 200 U/L, ALT: 25 U/L, Total bilirubin: 1.8 mg/dL, Urine protein: 2+.
Which of the following findings should the nurse report to the primary health care provider?
- A. Platelet count
- B. Hematocrit value
- C. Nonstress test result
- D. Weight gain
- E. Edema
- F. Blood pressure
- G. BUN
Correct Answer: A,D,E,F
Rationale: Low platelets, rapid weight gain, edema, high BP, and proteinuria indicate preeclampsia, requiring immediate reporting.
The nurse should first address the client's blood pressure followed by the client's platelet count.
Which of the following options correctly prioritizes these actions?
- A. Blood pressure should be checked before platelet count.
- B. Platelet count is more important than blood pressure.
- C. Address both simultaneously.
- D. Ignore blood pressure.
Correct Answer: A
Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.