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Client regarding how to reduce the risk of giving birth to a newborn who has a neural tube defect
Which of the following instructions by the nurse is appropriate?
- A. Increase intake of iron.
- B. Eat foods fortified with folic acid.
- C. Avoid the use of aspirin.
- D. Limit consumption of alcohol.
Correct Answer: B
Rationale: The correct answer is B: Eat foods fortified with folic acid. This instruction is appropriate because folic acid is crucial during pregnancy for preventing birth defects. Iron intake (A) is important too, but not the most appropriate here. Aspirin avoidance (C) is relevant due to its potential risks. Limiting alcohol (D) is important, but not as critical as folic acid. The other choices are not applicable or less crucial in this context.
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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.
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 18 weeks of gestation, felt light fluttering in stomach the previous day
The nurse should use which of the following terms to document this finding?
- A. Lightening
- B. Chloasma
- C. Ballotement
- D. Quickening
Correct Answer: D
Rationale: The correct answer is D: Quickening. Quickening refers to the first perception of fetal movements by the mother, typically around 16-20 weeks of gestation. It is an important milestone in pregnancy. Lightening (A) is the descent of the fetus into the pelvis. Chloasma (B) is a skin condition characterized by hyperpigmentation. Ballotement (C) is the rebounding of the fetus when the examiner pushes against the mother's abdomen. These terms are not relevant to the finding described in the question.
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.
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.