Nokea
Which response by the nurse is best?
- A. Any alcohol consumption during pregnancy will cause the child to have complications later in life.
- B. The minimal safe amount of alcohol consumption during pregnancy has not yet been determined.
- C. Alcohol consumption has a harmful effect on the baby only if consumed during the first trimester of pregnancy.
- D. Occasional intake of a small amount of alcohol during pregnancy will not adversely affect the unborn baby.
Correct Answer: B
Rationale: No safe level of alcohol consumption during pregnancy has been established, as it may cause fetal alcohol spectrum disorders.
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The pregnant client presents to the ED with a large amount of painless, bright red bleeding. She looks to be about 30 to 34 weeks pregnant based on her uterine size. She speaks limited English and is unable to communicate with the staff. Which actions should the nurse take? Select all that apply.
- A. Call for an interpreter for this client.
- B. Establish an intravenous access.
- C. Auscultate for fetal heart tones.
- D. Place the client into a lithotomy position.
- E. Perform a digital pelvic examination.
Correct Answer: A,B,C
Rationale: The nurse should call for an interpreter so that the client is able to communicate. An IV access should be performed by the nurse to administer any needed medications. Auscultating FHT will provide information about fetal well-being. Positioning the client in a lithotomy position can cause abdominal pain, and there is no indication that birth is imminent. The pregnant client who presents in later pregnancy should never have a digital pelvic examination because this could cause additional bleeding, especially if she has placenta previa.
While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client’s breasts are hard and painful. Which interventions should be implemented by the nurse? Select all that apply.
- A. Tell her to feed a small amount from both breasts at each feeding.
- B. Apply ice packs to the breasts at intervals between feedings.
- C. Give supplemental formula at least once in a 24-hour period.
- D. Administer an anti-inflammatory medication prescribed pm.
- E. Apply warm, moist packs to the breasts between feedings.
- F. Pump the breasts as needed to ensure complete emptying.
Correct Answer: B,D,F
Rationale: Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. Giving supplemental formula, thus limiting the time the baby nurses at the breast, prevents total emptying of the breast and promotes increased engorgement. Administering anti-inflammatory medication will decrease breast pain and inflammation. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement. Pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. Pumping at this time will not cause a problematic increase in breast milk production.
The experienced nurse instructs the new nurse that a vaginal examination should not be performed on the newly admitted client with possible grade 3 abruptio placentae. Which illustration shows the new nurse’s thinking about the uterus of the client with the grade 3 abruptio placentae?
- A. Illustration 1
- B. Illustration 2
- C. Illustration 3
- D. Illustration 4
Correct Answer: D
Rationale: Illustration 4 shows severe grade 3 abruptio placentae. More than 50% of the placenta separates with concealed hemorrhage. Illustration 1 shows complete placenta previa and not abruptio placentae. Illustration 2 shows partial placenta previa and not abruptio placentae. Illustration 3 shows mild grade 1 abruptio placentae. Less than 15% of the placenta separates with concealed hemorrhage.
The nurse is assessing pregnant clients. During which time frames should the nurse expect clients to report frequent urination throughout the night? Select all that apply.
- A. Before the first missed menstrual period
- B. During the first trimester
- C. During the second trimester
- D. During the third trimester
- E. One week following delivery
Correct Answer: B,D
Rationale: Urinary frequency is most likely to occur in the first and third trimesters. First-trimester urinary frequency occurs as the uterus enlarges in the pelvis and begins to put pressure on the bladder. In the third trimester, urinary frequency returns due to the increased size of the fetus and uterus placing pressure on the bladder. Women do not typically experience urinary changes before the first missed menstrual period. During the second trimester, the uterus moves into the abdominal cavity, putting less pressure on the bladder. Nocturnal frequency occurring a week after delivery may be a sign of a UTI.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.