Nokea
Which position should the nurse recommend for early labor?
- A. Lying flat on the back
- B. Walking or standing
- C. Sitting upright
- D. Kneeling on all fours
Correct Answer: B
Rationale: Walking or standing in early labor promotes progress and comfort, unlike lying flat, which may slow labor.
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Which intervention is most appropriate for a client experiencing low self-esteem during pregnancy?
- A. Encourage participation in a prenatal support group
- B. Prescribe antidepressants immediately
- C. Advise avoiding social interactions
- D. Ignore the issue as it is common
Correct Answer: A
Rationale: A prenatal support group fosters peer support and boosts self-esteem, addressing the client's emotional needs.
The nurse teaches the client to recognize which early labor sign?
- A. Bloody show
- B. Fatigue
- C. Increased appetite
- D. Mild nausea
Correct Answer: A
Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.
The pregnant client presents to a clinic with ongoing nausea, vomiting, and anorexia at 29 weeks’ gestation. Her Hgb level is 5 g/dL, and a blood smear reveals that newly formed RBCs are macrocytic. Which condition should the nurse further explore?
- A. Sickle cell anemia
- B. Folic acid deficiency anemia
- C. Beta-thalassemia minor
- D. Beta-thalassemia major
Correct Answer: B
Rationale: With the client’s symptoms and laboratory findings, the nurse should further explore folic acid deficiency. It is usually seen in the third trimester and coexists with iron-deficiency anemia. Sickle cell anemia is an inherited disorder in which the Hgb is abnormally formed. The chief symptom among individuals with sickle cell anemia is pain. Beta-thalassemia minor is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule. Beta-thalassemia minor typically results in mild anemia. Beta-thalassemia major is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule, but it is more severe than beta-thalassemia minor. Pregnancy in individuals with beta-thalassemia major is rare. Symptoms are usually severe anemia that warrants transfusion therapy.
The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake?
- A. Potassium
- B. Calcium
- C. Folic acid
- D. Sodium
Correct Answer: C
Rationale: The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
- A. An increase in maternal heart rate
- B. A decrease in the cardiac output
- C. An increase in the white blood cell (WBC) count
- D. A decreased intravascular volume during contractions
Correct Answer: A
Rationale: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.