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Client at 34 weeks of gestation, at risk for placental abruption
Which of the following is the most common risk factor for a placental abruption?
- A. Maternal battering
- B. Maternal cigarette smoking
- C. Maternal hypertension
- D. Maternal cocaine use
Correct Answer: C
Rationale: The correct answer is C: Maternal hypertension. Placental abruption is the premature separation of the placenta from the uterus before delivery. Hypertension can lead to reduced blood flow to the placenta, increasing the risk of abruption. Maternal battering (A) can cause trauma but is not the most common risk factor. Maternal cigarette smoking (B) and cocaine use (D) can also increase the risk but are not as prevalent as hypertension. Other factors may include advanced maternal age, multiple pregnancies, and previous history of placental abruption.
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Client in second trimester
The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?
- A. Increased abdominal muscle tone
- B. Decreased mobility of pelvic joints
- C. An increase in lordosis
- D. Posterior neck flexion
Correct Answer: C
Rationale: The correct answer is C: An increase in lordosis. During pregnancy, the center of gravity shifts forward due to the growing uterus, leading to an increase in the curvature of the lumbar spine (lordosis). This change helps to maintain balance and compensate for the added weight of the developing fetus. Increased abdominal muscle tone (choice A) is not an expected change as the abdominal muscles may actually stretch and weaken to accommodate the growing uterus. Decreased mobility of pelvic joints (choice B) is incorrect because during pregnancy, hormonal changes can actually increase the mobility of pelvic joints to prepare for childbirth. Posterior neck flexion (choice D) is unrelated to the physiologic changes in pregnancy.
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.
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.
Client in second trimester, new diagnosis of gestational diabetes
Which statement by the client indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will take my glyburide daily with breakfast.
- C. I will reduce my exercise schedule to 3 days a week.
- D. I know I am at increased risk to develop type 2 diabetes.
Correct Answer: C
Rationale: The correct answer is C because reducing the exercise schedule to 3 days a week contradicts the goal of managing type 2 diabetes through regular physical activity. Exercise helps control blood sugar levels and improves insulin sensitivity. Limiting exercise can lead to poor diabetes management. Choice A shows understanding of carbohydrate control. Choice B indicates adherence to medication regimen. Choice D demonstrates awareness of diabetes risk.
Client experiencing preterm labor, scheduled for amniocentesis
The client needs an amniocentesis to determine which of the following findings?
- A. Gender of the fetus
- B. Weeks of gestation
- C. Maturity of lungs
- D. Anatomic abnormalities
Correct Answer: C
Rationale: The correct answer is C: Maturity of lungs. Amniocentesis is a prenatal test that involves taking a sample of amniotic fluid to analyze fetal cells. The test can determine the maturity of the fetal lungs by measuring the level of surfactant, a substance produced by mature lungs. This information is crucial for assessing the fetus's lung function and determining the need for medical intervention if the lungs are not mature enough for birth.
Incorrect answers:
A: Gender of the fetus - Amniocentesis can determine the gender of the fetus, but this is not the primary purpose of the test.
B: Weeks of gestation - The gestational age can be estimated through ultrasound or other methods, not specifically through amniocentesis.
D: Anatomic abnormalities - While amniocentesis can detect some genetic abnormalities, it is not primarily used to detect anatomic abnormalities.