Nokea
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Fetal heart tones 98 /min
- B. Foul smelling vaginal discharge
- C. Amniotic fluid with meconium noted
- D. Maternal temperature 38.3°C (101°F)
Correct Answer: A
Rationale: Fetal bradycardia (98/min) indicates distress, requiring immediate intervention due to possible cord prolapse after membrane rupture.
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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. CBC
- B. Serum bilirubin
- C. Urinalysis of ketones
- D. Liver enzymes
Correct Answer: C
Rationale: Urinalysis for ketones is the priority as it indicates ketosis from prolonged vomiting, guiding the need for IV fluids and nutritional support in hyperemesis gravidarum.
A nurse is collecting data from a client who is at 28 weeks of gestation.
Which of the following findings is the nurse's priority?
- A. FHR 160/min
- B. Fundal height 24 cm
- C. Blood pressure 136/84 mm Hg
- D. Trace protein on urine reagent strip
Correct Answer: B
Rationale: A fundal height of 24 cm at 28 weeks is lower than expected, suggesting intrauterine growth restriction, requiring further evaluation.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?
- A. Position the lap belt across your navel.
- B. Wear the shoulder harness snug across your stomach.
- C. Take a break and walk at least once every hour during long trips.
- D. Move your car seat forward, close to the steering wheel.
Correct Answer: C
Rationale: Walking every hour during long trips improves circulation and reduces the risk of deep vein thrombosis.
A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Stroke upward on the lateral aspect of the sole of the newborn's foot.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Pull the newborn up by the wrist from a supine position
- D. Touch the corner of the newborn's mouth
Correct Answer: A
Rationale: The Babinski reflex is elicited by stroking the lateral sole of the foot, causing dorsiflexion of the big toe and fanning of other toes in newborns.