A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?

Correct Answer: C

Rationale: The correct answer is C: Hydatidiform mole. At 4 months of gestation, prune-colored discharge indicates possible passage of vesicular tissue characteristic of a molar pregnancy. This, along with continued nausea, vomiting, and larger fundal height, are signs of a hydatidiform mole. Hyperemesis gravidarum (A) typically involves severe nausea and vomiting leading to weight loss, which the client did not experience. Threatened abortion (B) presents with vaginal bleeding and cramping, not prune-colored discharge. Preterm labor (D) is characterized by regular contractions leading to cervical changes, not the symptoms described.

Correct Answer: C

Rationale: To calculate the mL/hr for the IV infusion pump, we need to use the formula: (Desired dose in mg/hr * Volume of solution in mL) / Concentration of solution in mg/mL. Given: Desired dose = 2 g/hr = 2000 mg/hr Volume of solution = 500 mL Concentration of solution = 20 g in 500 mL = 20,000 mg in 500 mL = 40 mg/mL Now, plug these values into the formula: (2000 mg/hr * 500 mL) / 40 mg/mL = 25,000 mL/hr Round this to the nearest whole number, which is 25,000 mL/hr ≈ 50 mL/hr. Therefore, the IV infusion pump should be set to administer 50 mL/hr, making choice C the correct answer. Option A (60 mL/hr) and Option D (80 mL/hr) are incorrect as they do not match the calculated value. Option

Correct Answer: D

Rationale: The correct answer is D: All of the above. Magnesium sulfate is contraindicated in cases of fetal distress, cervical dilation greater than 6 cm, and vaginal bleeding. Fetal distress can be worsened by magnesium sulfate, and it can lead to respiratory depression in the newborn. Cervical dilation greater than 6 cm indicates advanced labor, where the risk of uterine atony and postpartum hemorrhage is increased with magnesium sulfate use. Vaginal bleeding may be a sign of placental abruption or other complications, which can be exacerbated by magnesium sulfate. Therefore, all three options are contraindications for the use of magnesium sulfate in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Assist the client to the bathroom to void. This action can help promote uterine contractions by relieving bladder distention, which can cause the fundus to be displaced. Voiding can help the uterus return to its normal position and firmness. Placing the client in a side-lying position (A) may be helpful for fundal massage but addressing bladder distention is the priority. Obtaining a prescription for IV oxytocin (C) or administering methylergonovine (D) are not indicated as first-line interventions for a fundus located above the umbilicus postpartum.

Correct Answer: D

Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother. A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.

Correct Answer: D

Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) helps determine the well-being of the baby after the water breaking. Monitoring the FHR can indicate if the baby is in distress and prompt further actions if needed. Performing Nitrazine testing (choice A) is used to confirm if the fluid is amniotic fluid, but FHR monitoring takes precedence. Assessing the fluid (choice B) is important but not as urgent as monitoring the FHR. Checking cervical dilation (choice C) is not the priority as ensuring the baby's well-being through FHR monitoring is crucial in this situation.

Correct Answer: A

Rationale: Step 1: Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours after unprotected sex. Step 2: Taking the medication within the specified time frame increases its effectiveness in preventing pregnancy. Step 3: Thus, the nurse should emphasize to the adolescent the importance of taking the medication promptly after unprotected intercourse. Step 4: This information is crucial for the adolescent to understand the time-sensitive nature of levonorgestrel contraception. Summary: - Choice B is incorrect because it provides contradictory information. Levonorgestrel can be taken even if the individual is on an oral contraceptive. - Choice C is incorrect as starting a period is not a reliable indicator of pregnancy. A pregnancy test is recommended if there are concerns. - Choice D is incorrect because levonorgestrel is a single-dose emergency contraception and does not provide protection for 14 days.

Correct Answer: C

Rationale: The correct answer is C: Petechiae over the head. This is because tight nuchal cord can cause pressure on the baby's head during delivery, leading to tiny red or purple spots called petechiae due to capillary rupture. Bruising over the buttocks (A) is more common in breech deliveries, hard nodules on the roof of the mouth (B) could indicate Epstein pearls which are benign and common in newborns, and bilateral periauricular papillomas (D) are not related to nuchal cord compression.

Correct Answer: B

Rationale: The correct answer is B. The blotchy hyperpigmentation on the client's forehead is likely melasma, a common occurrence during pregnancy. This is due to hormonal changes causing increased melanin production. The nurse should educate the client that this is an expected occurrence during pregnancy and reassure her that it is usually temporary and will fade postpartum. Choice A (Tell the client to follow up with a dermatologist) is incorrect because dermatological consultation is not typically necessary for melasma during pregnancy. Choice C (Instruct the client to increase her intake of vitamin D) is incorrect because vitamin D deficiency is not typically associated with blotchy hyperpigmentation on the forehead during pregnancy. Choice D (Inform the client she might have an allergy to her skin care products) is incorrect because melasma is not caused by allergies to skincare products.