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Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Heart rate of 56 beats/minute.
- B. Saturating two perineal pads per hour.
- C. Soft, spongy fundus.
- D. Unilateral lower leg pain.
Correct Answer: A
Rationale: Bradycardia (56 beats/minute) is normal postpartum due to increased stroke volume, unlike excessive bleeding, uterine atony, or DVT signs.
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A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
- A. Start oxytocin infusion immediately.
- B. Begin oxytocin 4 hours after misoprostol is given.
- C. Ambulate the client after administration of misoprostol.
- D. Administer misoprostol every 2 hours.
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?
- A. Passive immunity in the first months of life provides protection in newborns.
- B. Infants can receive antiinfectants that have not developed resistance to microbes.
- C. Active immunity in newborns is developed fully in the first month of life.
- D. Neutrophils may be immature in protecting neonates from the risk for infection.
Correct Answer: A
Rationale: Passive immunity from maternal antibodies provides newborns with initial protection against communicable diseases, lasting several months until their immune system matures.
A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.
- B. Perform sterile vaginal examination to determine dilatation.
- C. Assess the fetal heart rate and client's contraction pattern.
- D. Determine fetal position by performing Leopold maneuvers.
Correct Answer: C
Rationale: Bright red vaginal bleeding suggests possible placental issues; assessing fetal heart rate and contraction pattern is critical to detect fetal distress and guide urgent interventions.