Nokea
Which of the following should the nurse plan to have available when providing nursing care to this client? Select all that apply.
- A. I.V. start kit
- B. An intake and output record
- C. Oxygen and face mask
- D. Cardiac monitor
- E. A consent for a blood transfusion
- F. A suction machine
Correct Answer: A,B,C,F
Rationale: Hyperemesis gravidarum with dehydration requires I.V. fluids, intake/output monitoring, oxygen if needed, and suction for vomiting.
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The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
- A. Falling beta human chorionic gonadotropin (BHCG) measurement
- B. Low progesterone measurement
- C. Ultrasound showing a lack of fetal cardiac activity
- D. Ultrasound determining crown-rump length
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.
What information should the nurse also include about the side effects of iron supplementation?
- A. You may notice that your stools will be black.
- B. Your teeth will become stained.
- C. Vomiting is likely to occur.
- D. You may have diarrhea several times per day.
Correct Answer: A
Rationale: Black stools are a common side effect of iron supplements due to unabsorbed iron, unlike the other options.
Before teaching the client about the nutritional needs during pregnancy, which nursing intervention is most appropriate?
- A. Determine if the client needs to gain or lose weight.
- B. Assess the client's current eating pattern and preferences.
- C. Determine if the client knows how to accurately count calories.
- D. Develop a sample menu that includes the required nutrients.
Correct Answer: B
Rationale: Assessing the client's eating patterns and preferences provides a baseline for tailored nutritional education.
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
- A. Weekly for the remainder of the pregnancy
- B. Every 2 weeks for the remainder of the pregnancy
- C. Every 2 weeks up to 36 weeks, then weekly for the last month
- D. Weekly up to 36 weeks, then twice weekly for the last month
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
- A. Administer oxygen via facemask
- B. Have the HCP paged if the prolonged decelerations have not resolved.
- C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.
- D. Increase the rate of the intravenous (IV) fluids
- E. Assist the client into a different position
- F. Prepare for a vaginal examination and fetal scalp stimulation
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.