A nurse is caring for a client who is 32 weeks gestation who comes to the emergency department for painful bleeding. Which is the priority nursing assessment?

Correct Answer: C

Rationale: The correct priority nursing assessment in this scenario is to assess for hemorrhage (Choice C). This is crucial because painful bleeding in a client at 32 weeks gestation could indicate a potential life-threatening situation such as placental abruption or placenta previa. Assessing for hemorrhage involves checking the amount and type of bleeding, vital signs, and signs of shock. It is essential to identify and address hemorrhage promptly to prevent adverse outcomes for both the mother and the baby. Monitoring for contractions (Choice A) is important but assessing for hemorrhage takes precedence due to the immediate risk it poses. Assessing the pain level (Choice B) is secondary to assessing for hemorrhage in this case. Providing emotional support (Choice D) is important but should come after ensuring the client's physical well-being is addressed.

Correct Answer: B

Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect may indicate pulmonary edema. This condition occurs due to fluid accumulation in the lungs, leading to symptoms like coughing. The increased blood volume and pressure during pregnancy can exacerbate the client's existing heart condition, resulting in pulmonary edema. Orthopnea (choice A) is difficulty breathing when lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not typically associated with a nonproductive cough. Decreased blood volume (choice D) would not directly lead to a nonproductive cough on minimal exertion.

Correct Answer: C

Rationale: Rationale: 1. HbA1c reflects average blood glucose levels over the past 2-3 months. 2. A value of 10% indicates poor blood glucose control. 3. High HbA1c (above 6.5-7%) signifies uncontrolled diabetes. 4. Choice C is correct as it aligns with the interpretation of HbA1c. Summary: - Choice A is incorrect as 10% is not a normal HbA1c value. - Choice B is incorrect as a low value would indicate good control. - Choice D is incorrect as HbA1c is a key marker for diabetes management.

Correct Answer: B

Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is the recommended plan because current guidelines suggest administering intrapartum prophylaxis with penicillin for GBS-positive pregnant women to prevent neonatal GBS disease. Choice A is incorrect because sending a GBS to the laboratory immediately is unnecessary since the previous positive culture result is already known. Choice C is incorrect because follow-up cultures are not routinely recommended at 38 weeks gestation. Choice D is incorrect because determining if the patient received antibiotics for the positive strep does not address the need for intrapartum prophylaxis specifically with penicillin.

Correct Answer: A

Rationale: The correct answer is A because administering antiretroviral drugs as ordered helps reduce the risk of vertical transmission of HIV from mother to baby during childbirth. This treatment is essential in managing the client's HIV status and ensuring the safety of the newborn. Choice B is incorrect because using a labor ball does not directly address the HIV status of the client or the transmission risk to the newborn. Choice C is incorrect as wearing gloves when handling the newborn does not replace the need for antiretroviral therapy to prevent transmission. Choice D is incorrect because breastfeeding can transmit HIV from mother to baby, so it is not recommended for HIV-positive mothers to breastfeed.