Nokea
A nurse is assisting with the admission of a client who has hyperemesis gravidarum.
Which of the following laboratory tests is the priority to complete?
- A. Urinalysis for ketones.
- B. Serum bilirubin.
- C. Liver enzymes.
- D. Complete blood count.
Correct Answer: A
Rationale: Urinalysis for ketones is the priority to assess dehydration and nutritional status, critical in managing hyperemesis gravidarum.
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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.
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. Urinary urgency and frequency.
- D. Perineal itching and pressure.
Correct Answer: C
Rationale: Urinary urgency and frequency are common in the first trimester due to hormonal changes and increased pelvic blood flow, pressing on the bladder.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
History and Physical: The client reports a history of one previous cesarean section due to breech presentation. She smokes half a pack of cigarettes daily and has a BMI greater than 30. The client denies leakage of amniotic fluid and describes positive fetal movement. Vital Signs: Temperature: 98.6°F (37°C), Pulse: 88 beats/min, Respiratory Rate: 16 breaths/min, Blood Pressure: 128/78 mmHg, Oxygen Saturation: 98% on room air. Nurses' Notes (0830 and 0845): 0830: The client is grimacing and reports discomfort. Fetal heart rate is 148 beats per minute. Fundal height measures 28 cm. 0845: Uterine contractions every 2 to 3 minutes, moderate in intensity, lasting 60 seconds.
The nurse should recommend to first address the client's ___, followed by the client's ___.
- A. Uterine contraction frequency
- B. History of cesarean delivery
Correct Answer: A,B
Rationale: Frequent contractions indicate preterm labor risk at 30 weeks; prior cesarean increases uterine rupture risk, both needing prompt attention.
A nurse is caring for a 37-year-old female client in the labor and delivery unit in early labor with contractions and reports feeling fetal movement.
The nurse should anticipate a provider's prescription for ___ due to the client’s ___.
- A. Continuous fetal monitoring , term gestation with regular contractions
- B. regular exercise,fetal positioning
Correct Answer: A
Rationale: Continuous fetal monitoring ensures observation of fetal heart rate and labor progress in a term client with regular contractions.