212. Amniocentesis at 16 weeks' gestation; nurse instructs client:
That the bladder must be full during exam.(To support weight of uterus)(After 20 wks. bladder empty to minimize chance of puncturing placenta or fetus.
213. Client 28 wks. Rh negative: nurse determines client understands Rh sensitization when:
I will tell the nurse at the hospital that I had RhoGAM during pregancy. (Accepted practice to administer RhoGAM to woman at 28 wks. , with 2nd injection within 72 hrs. of delivery.)
214. Measuring fundal height; client 36 wks. gestation states she is feeling lightheaded; nurse determines this is due to:
Compression of vena cava. (Suppression of vena cava by uterus may cause supine hypotension syndrome. Have woman turn onto L side or elevating R buttock during fundal height measurement.)
215. Contraction stress test; most accurate description:
The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation. (Contraction stress test assess placental O2 and function and determines fetus' ability to tolerate labor as well as its well-being. Performed if
216. Client at 38 wks. in early labor; carrying twins, one in breech presentation. Which is lowest priority?
Measuring fundal height
(Other 3 options are high priority: Attaching electronic fetal monitoring. Preparing client for cesarean section. Gathering equipment for starting an IV.)
217. Client w/ exacerbation of heart condition; consult w/dietitian for nutritional requirements:
A diet that is high in fluids and fiber to decrease constipation.
(clients w/constipation use Valsalva's maneuver, this causes blood to rush to heart and overload cardiac system. - not good for heart condition)
218. Nurse caring for client w/abruptio placentae; monitoring client for signs of disseminated intravascular coagulopathy (DIC); nurse would suspect DIC if she observes:
Petechiae, oozing from injection sites and hematuria.
(DIC is state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding)
219. Nurse teaching client regarding iron supplementation to prevent anemia; which statement indicates teaching successful:
The iron is needed for red blood cells.
220. Client w/diabetes mellitus; effective teaching
I need to increase fiber in my diet to control by blood glucose and prevent constipation.
(The client w/diabetes needs about 50-60% calories from carbohydrates; 12-20% from protein. High-fiber foods will control blood glucose levels and prevent constipati
221. Client at risk for eclampsia; if progresses from preeclampsia to eclampsia, nurse's 1st action should be:
Clear and maintain an open airway.
(Administer oxygen by face mask. Check BP and FH tones. Prepare for adminisration of IV magnesium sulfate. - are components of care, but not 1st action)
222. Client in 2nd trimester; complains of frequent low back pain and ankle edema; nurse recommends:
Lie on floor w/legs elevated onto a couch or padded chair, w/hips and knees at right angle.
(This position will produce pelvic tilt while countering gravity as force that leads to edema of lower extremities.)
223. Client w/ leg cramps
Dorsiflex the client's foot while extending the knee.
224. Client w/heartburn; measures to alleviate discomfort:
Drink decaffeinated coffee and tea.
(Lying down after meals causes reflux of stomach contents. Spices trigger heartburn. Salt lead to fluid retention. Eating smaller portions preferrable to eating larger. Caffeine causes heartburn.)
225. 48 hr postpartum check on client w/gestational hypertension (GH). Which indicates not resolving?
The client complains of a headache and blurred vision.
(Urinary output has increased. There is no evidence of dependent edema. The BP reading has returned to prental baseline. - all indicate improvement)
226. Client w/GH, signs of preeclampsia:
Proteinuria
Hypertension
Generalized edema
(low grade fever, increased pulse rate, increased respiratory rate - not associated w/preeclampsia)