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A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Pedal edema
- B. BP of 132/84 mm Hg
- C. Weight gain of 1 kg (2.2 lb)
- D. Double vision
Correct Answer: D
Rationale: Double vision can indicate preeclampsia or other serious conditions in pregnancy, requiring prompt reporting for further evaluation and management.
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A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Tell the client to apply hydrocortisone ointment to the affected area of the breast.
- B. Suggest the client apply warm compresses to the affected breast
- C. Recommend the client avoid wearing a nursing bra until symptoms resolve
- D. Encourage the client to limit oral fluid intake to decrease milk production
Correct Answer: B
Rationale: Applying warm compresses to the affected breast can help relieve pain and promote milk flow, which can aid in resolving the infection. Warmth can help reduce inflammation and make breastfeeding or pumping less painful.
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 Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- B. A group B streptococcus screening will be performed to determine the presence of STs.
- C. A multiple marker screening will be performed to identify neural tube defects.
- D. A glucose tolerance test will be performed to predict hyperglycemia in your baby
Correct Answer: C
Rationale: Multiple marker screening, also known as maternal serum screening or quad screen, is a routine prenatal test performed between 15 and 20 weeks of gestation. It helps identify the risk of certain chromosomal abnormalities, including neural tube defects like spina bifida and anencephaly.
A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes.
Which of the following actions is the highest priority?
- A. Perform fundal massage
- B. Weigh the perineal pad
- C. Apply oxygen by face mask
- D. Monitor urine output
Correct Answer: A
Rationale: Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, potentially indicating postpartum hemorrhage. Fundal massage stimulates uterine contractions to control bleeding by compressing blood vessels at the placental site, making it the highest priority action.
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who smokes one pack of cigarettes per day
- B. A client who has a history of gallbladder disease
- C. A client who has a positive pregnancy test
- D. A client who is nulliparous
Correct Answer: C
Rationale: An IUD should not be inserted in a client who has a positive pregnancy test. Inserting an IUD during pregnancy can lead to complications such as infection, miscarriage, and preterm birth. It is crucial to confirm the absence of pregnancy before IUD insertion.
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. Prepare the client for an abdominal sonogram.
- B. Encourage the client to continue to breastfeed
- C. Encourage the client to wear a bra that is loose fitting
- D. Limit the client's daily fluid intake.
Correct Answer: B
Rationale: Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.