ATI RN
Complications in Early Pregnancy Questions
Question 1 of 5
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 answer is C: Assess for hemorrhage. This is the priority assessment as the client is experiencing painful bleeding, indicating a potential hemorrhage which can be life-threatening. Assessing for hemorrhage will help identify the severity of the situation and guide immediate interventions. Monitoring for contractions (choice A) is important but assessing for hemorrhage takes precedence. Assessing pain level (choice B) is important but addressing the potential hemorrhage is more critical. Providing emotional support (choice D) is important but should come after addressing the urgent medical need of assessing for hemorrhage.
Question 2 of 5
During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
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 suggests pulmonary edema. This is due to fluid accumulation in the lungs, leading to coughing. Pulmonary edema can occur due to increased blood volume and pressure on the heart during pregnancy, exacerbating the client's pre-existing heart condition. Orthopnea (choice A) is difficulty breathing while lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not directly linked to a nonproductive cough. Decreased blood volume (choice D) is unlikely in a pregnant client and would not explain the cough.
Question 3 of 5
A nurse is monitoring a client with type 2 diabetes mellitus. Her blood work reveals a glycosylated hemoglobin (HbA1c) of 10%. The nurse knows this blood work indicates which of the following?
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 (like 10%) signifies uncontrolled diabetes. 4. Choice C is correct due to the high HbA1c value. Summary: A: Incorrect as 10% is high, not normal. B: Incorrect, as 10% is high, not low. D: Incorrect, as HbA1c does offer information regarding diabetes management.
Question 4 of 5
The labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns. A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known. C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines. D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
Question 5 of 5
The nurse is caring for a client in labor who is HIV positive. Which nursing care should be included?
Correct Answer: A
Rationale: The correct answer is A: Administering antiretroviral drugs as ordered. This is crucial in preventing vertical transmission of HIV from mother to child during childbirth. Antiretroviral therapy reduces the viral load in the mother's blood and bodily fluids, decreasing the risk of transmission. Choice B is beneficial for labor progress but not directly related to HIV care. Choice C is unnecessary as HIV is not transmitted through skin contact. Choice D is contraindicated as breastfeeding can transmit HIV from mother to child.