Nokea
While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
- A. Tell the client to leave the boyfriend immediately.
- B. Ask the client when she last felt the baby move.
- C. Refer the client to a social worker for possible options.
- D. Report the incident to the unit nursing supervisor.
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.
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After reinforcing the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statements would demonstrate her understanding of when to call the physician's office? Select all that apply.
- A. "If I get up in the morning and feel dizzy, even if the dizziness goes away."
- B. "If I see any bleeding, even if I have no pain."
- C. "If I have a pounding headache that doesn't go away."
- D. "If I notice the veins in my legs getting bigger."
- E. "If the leg cramps at night are waking me up."
- F. "If the baby seems to be more active than usual."
Correct Answer: A,B,C,F
Rationale: These symptoms could indicate complications needing medical attention.
A multigravid client at 39 weeks' gestation diagnosed with insulin-dependent diabetes is admitted for induction of labor with oxytocin (Pitocin). Which of the following should the nurse include in the teaching plan as a possible disadvantage of this procedure?
- A. Urinary frequency.
- B. Maternal hypoglycemia.
- C. Preterm birth.
- D. Neonatal jaundice.
Correct Answer: B
Rationale: Oxytocin induction in diabetic clients increases metabolic demand, risking maternal hypoglycemia due to insulin use. Urinary frequency is unrelated, preterm birth is not a concern at 39 weeks, and neonatal jaundice is not directly linked.
A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess?
- A. Uterine cramping.
- B. Abdominal distention.
- C. Hemoglobin and hematocrit.
- D. Pulse rate.
Correct Answer: D
Rationale: Pulse rate helps assess circulatory status.
Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding?
- A. Breast milk quality and richness are decreased.
- B. The mother's motivation to breast-feed is diminished.
- C. Medications may be excreted in breast milk to the nursing neonate.
- D. Medications interfere with the mother's letdown reflex.
Correct Answer: C
Rationale: Medications can pass into breast milk, potentially affecting the neonate, making this the primary concern.
A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?
- A. Withdrawal symptoms usually do not occur until 7 days postpartum.
- B. Large-for-gestational-age size is common with this condition.
- C. Facial deformities associated with FAS can be corrected by plastic surgery.
- D. Symptoms of withdrawal include tremors, sleeplessness, and seizures.
Correct Answer: D
Rationale: Symptoms of withdrawal in FAS include tremors, sleeplessness, and seizures due to neurological effects of alcohol exposure.