Which statement made by a participant regarding remedies of heartburn and nausea indicates that teaching has been effective?
- A. I should eat frequent, small meals.
- B. I should take an antacid after eating.
- C. I should eat my largest meal in the evening.
- D. I should drink extra water with my meals.
Correct Answer: A
Rationale: Frequent, small meals reduce stomach acid and nausea, unlike large meals or extra water, which may worsen symptoms.
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The nurse uses which tool to measure fundal height?
- A. Tape measure
- B. Doppler device
- C. Ultrasound machine
- D. Blood pressure cuff
Correct Answer: A
Rationale: A tape measure is used to measure fundal height, assessing uterine growth and fetal development.
Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
- A. Document the data in the client’s health care records
- B. Notify the health care provider immediately
- C. Administer a laxative that has been prescribed pm
- D. Assess the client’s abdomen and bowel sounds
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.
The client is diagnosed with pregnancy-related diabetes at 28 weeks’ gestation. In teaching the client, the nurse includes which information for managing her blood glucose levels? Select all that apply.
- A. Drawing glycosylated hemoglobin A1c levels
- B. Performing home blood glucose monitoring
- C. Developing a weight management plan
- D. Engaging in appropriate daily exercise
- E. Taking oral diabetic agents in the am.
Correct Answer: A,B,C,D
Rationale: Hgb A1c will be drawn and monitored throughout the pregnancy, with a goal of reaching a level of less than 7%. Home blood glucose monitoring will help the client identify when her blood glucose is outside normal parameters. Excessive weight gain worsens control of glucose levels. Exercise adapted for the pregnant body is important to glucose control. Oral diabetic agents are contraindicated in pregnant clients.
The nurse is caring for the client who is Rh negative at 13 weeks’ gestation. The client is having cramping and has moderate vaginal bleeding. Which HCP order should the nurse question?
- A. Administer Rho(D) immune globulin (RhoGAM).
- B. Obtain a beta human chorionic gonadotropin level (BHCG).
- C. Schedule for an immediate ultrasound.
- D. Place on continuous external fetal monitoring.
Correct Answer: B
Rationale: Obtaining the BHCG level is not indicated at 13 weeks’ gestation. BHCG levels are followed in early pregnancy before a fetal heartbeat can be confirmed. RhoGAM is indicated for any pregnant client with bleeding who is Rh negative. An ultrasound can identify the cause of bleeding and confirm fetal viability. Continuous external fetal monitoring can be used to confirm a fetal heartbeat, fetal viability, and fetal risk.
Which laboratory test should the nurse monitor for a client with preeclampsia?
- A. Platelet count
- B. Blood glucose
- C. Cholesterol levels
- D. Thyroid function
Correct Answer: A
Rationale: Monitoring platelet count is critical in preeclampsia, as low platelets may indicate severe disease or HELLP syndrome.