A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?

Correct Answer: B

Rationale: The nurse should auscultate the fetal heart rate during the prenatal visit for the client who has a crown-rump length of 7 weeks gestation. At this stage, the fetal heart is usually visible on ultrasound, and auscultating the fetal heart rate can provide valuable information about the health and development of the fetus. It is an important part of prenatal care to monitor the fetal heart rate regularly to ensure the well-being of the baby. In the other scenarios provided:

Correct Answer: B

Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.

Correct Answer: C

Rationale: Epidural anesthesia can result in some common side effects, one of which is pruritus (itching). Pruritus is a known side effect of the local anesthetics used in epidural anesthesia and is due to their effects on specialized receptors in the nervous system. Patients may experience itching, especially in the face, neck, and upper chest areas. Polyuria (increased urine output), hypertension (high blood pressure), and dry mouth are not typically associated side effects of epidural anesthesia.

Correct Answer: A

Rationale: A previous history of depression is a significant risk factor for postpartum depression. Women who have experienced a depressive episode in the past are more likely to develop postpartum depression compared to those without such a history. Recognizing this pertinent data in the patient's history can help the nurse identify individuals at higher risk for postpartum depression and provide appropriate support and intervention. The other options mentioned (B. Unexpected operative birth, C. Ambivalence during the first trimester, D. Second pregnancy in a 3-year period) may also contribute to emotional distress but are not as directly linked to postpartum depression as a previous depressive episode.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer. The nurse should educate the G1P0 client that she should gain 3.5 to 5 pounds in the first trimester and 1 pound per week in the last two trimesters. This information is crucial for the client to understand appropriate weight gain during pregnancy, which is vital for the health of both the mother and the developing fetus. Option B, contraception options after delivery, is not relevant to the client's current situation in the third trimester and does not address the educational need at this time. Option C, which states that the client should gain 10 pounds in each trimester, is incorrect as it provides inaccurate information about weight gain during pregnancy. Option D, regarding Group B strep (GBS) screening, is important but not directly related to the client's current educational needs about weight gain. Educationally, understanding appropriate weight gain during pregnancy is essential for prenatal care and ensuring optimal health outcomes for both the mother and the baby. Providing accurate information empowers the client to make informed decisions and engage in healthy behaviors throughout her pregnancy. By focusing on the correct answer, the nurse can support the client in achieving a healthy pregnancy and delivery.