Nokea
Client possible ectopic pregnancy at 8 weeks of gestation
Which of the following findings should the nurse expect?
- A. Pelvic pain
- B. Severe nausea and vomiting
- C. Copious vaginal bleeding
- D. Uterine enlargement greater than expected for gestational age
Correct Answer: A
Rationale: The correct answer is A: Pelvic pain. This finding is indicative of ectopic pregnancy, where the fertilized egg implants outside the uterus, often causing pelvic pain due to fallopian tube stretching or rupture. Severe nausea and vomiting (B) can occur in normal pregnancy but are not specific to ectopic pregnancy. Copious vaginal bleeding (C) is more commonly seen in miscarriage. Uterine enlargement greater than expected for gestational age (D) would be expected in a normal intrauterine pregnancy, not in ectopic pregnancy.
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Client just learned she is pregnant
The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?
- A. Decreased energy
- B. Mood swings
- C. Urinary frequency
- D. Facial edema
Correct Answer: D
Rationale: The correct answer is D: Facial edema. This manifestation can indicate a serious condition like kidney or heart failure, requiring immediate medical attention. Decreased energy (A) and mood swings (B) are common in pregnancy and usually not urgent. Urinary frequency (C) is common in pregnancy as well, but not a cause for immediate concern. Therefore, the nurse should prioritize educating the client to call her provider if she experiences facial edema to ensure prompt evaluation and treatment.
Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.
Client at first prenatal visit
Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.
- A. Breast tenderness
- B. Nausea and vomiting
- C. Quickening
- D. Goodell's sign
- E. Striae gravidarum
- F. Lightening
Correct Answer: A,B,C,D,E,F
Rationale: The correct order is A, B, C, D, E, F. Firstly, breast tenderness (A) typically occurs early in pregnancy due to hormonal changes. Next, nausea and vomiting (B) often start around the 6th week. Quickening (C), the first fetal movements felt by the mother, occurs around 16-20 weeks. Goodell's sign (D), softening of the cervix, happens around the 6th-8th week. Striae gravidarum (E), stretch marks, appear later in pregnancy due to skin stretching. Finally, lightening (F), when the baby drops lower in the pelvis, occurs in the last few weeks before labor. Other options are incorrect as they do not follow the chronological order of gestation milestones.
Client at 34 weeks of gestation, suspected placenta previa
Which of the following actions should the nurse take?
- A. Perform a rectal exam.
- B. Apply an external fetal monitor.
- C. Complete a vaginal exam.
- D. Apply ice to the perineal area.
Correct Answer: B
Rationale: The correct answer is B: Apply an external fetal monitor. This action is crucial in monitoring the fetal heart rate and uterine contractions during labor, ensuring the well-being of both the mother and the baby. Performing a rectal exam (choice A) is not indicated in this context. Completing a vaginal exam (choice C) may be necessary but is not the immediate priority. Applying ice to the perineal area (choice D) is not relevant for fetal monitoring. Other choices are not provided.
Adult patient, physician orders Magnesium 4 gms loading dose to infuse over 30 minutes at 0500, then infuse a maintenance dose of 1 gram/hr, pharmacy sends 80 Gms in 1000 mL of LR
What would the nurse set the pump for the loading dose at 5 Am? Be sure to enter the number AND the unit of measurement (mL).
Correct Answer: 200 mL/hr
Rationale: The correct answer is 200 mL/hr. At 5 AM, the nurse would set the pump for the loading dose based on the prescribed rate per hour. By setting the pump at 200 mL/hr, the patient will receive the intended dose over the specified time. Choices A-G are incorrect as they do not align with the standard dosing calculations for the loading dose at 5 AM.