The nurse is assessing a client at 10 weeks' gestation. Which finding is expected?

Correct Answer: B

Rationale: In the assessment of a client at 10 weeks' gestation, the expected finding would be fetal heart tones by Doppler (Option B). This is because at around 10-12 weeks of gestation, fetal heart tones can be detected using a Doppler ultrasound device. This finding indicates the presence of a viable pregnancy and is a crucial milestone in prenatal care. Option A, quickening, is the sensation of fetal movements typically felt by the mother around 18-20 weeks of gestation, not at 10 weeks. Option C, fundus at the level of the umbilicus, is expected around 20-22 weeks, not at 10 weeks when the uterus is still within the pelvic cavity. Option D, Braxton Hicks contractions, are irregular, painless contractions that are commonly felt in the third trimester, not typically present at 10 weeks. Educationally, understanding the timing of different prenatal assessments and findings is crucial for nurses caring for pregnant clients. Knowing the expected milestones helps in providing appropriate care, assessing fetal well-being, and detecting any deviations from normal development. This knowledge also aids in building a trusting relationship with the client and promoting positive maternal and fetal outcomes.

Correct Answer: B

Rationale: The most reliable diagnostic test for suspected gestational diabetes is the Oral Glucose Tolerance Test (OGTT). This test involves the client fasting overnight and then drinking a glucose solution followed by blood draws to measure glucose levels at specific intervals. The OGTT is considered the gold standard for diagnosing gestational diabetes because it provides a more comprehensive assessment of the body's ability to regulate glucose levels over time. It can detect abnormalities in glucose metabolism that may not be captured by a single blood glucose measurement. In contrast, a random blood glucose test (Option A) may not provide an accurate representation of the client's glucose tolerance as it can be influenced by recent food intake. A fasting blood glucose test (Option C) only provides a snapshot of glucose levels at one point in time and may miss postprandial hyperglycemia common in gestational diabetes. Hemoglobin A1C (Option D) is not recommended for diagnosing gestational diabetes as it reflects average blood glucose levels over the past 2-3 months and may not capture recent changes in glucose metabolism during pregnancy. Educationally, understanding the rationale behind diagnostic tests for gestational diabetes is crucial for nurses caring for pregnant clients. By knowing the strengths and limitations of each test, nurses can advocate for appropriate screening and diagnostic procedures to ensure the best outcomes for both the mother and baby.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, the priority preoperative nursing action for a client undergoing a postpartum tubal ligation is to verify signed informed consent, which is option B. This is crucial because informed consent is a legal and ethical requirement that ensures the client fully understands the procedure, risks, benefits, and alternatives before proceeding. By verifying the signed informed consent, the nurse ensures that the client has made an informed decision and is aware of what will happen during the procedure, promoting patient autonomy and safety. Inserting an indwelling catheter (option A) is not the priority preoperative nursing action in this scenario unless specifically indicated by the healthcare provider based on the client's individual needs. Administering prescribed antibiotics (option C) and checking for maternal vital signs (option D) are important aspects of preoperative care but do not take precedence over verifying informed consent, which is essential for protecting the client's rights and ensuring a safe and ethical care environment. Educationally, understanding the importance of informed consent in healthcare settings is critical for nurses and other healthcare professionals. It is a fundamental aspect of patient care that upholds ethical principles and legal standards. By prioritizing informed consent, nurses demonstrate respect for the client's autonomy, promote shared decision-making, and contribute to the overall quality and safety of care provided to maternal newborn clients undergoing surgical procedures like tubal ligation.

Correct Answer: A

Rationale: In educating pregnant clients about kick counts, it is crucial to emphasize the significance of fetal movement as an indicator of fetal well-being. The correct answer is A) Fewer than 10 movements in 2 hours because a decrease in fetal movements could signal potential fetal distress and requires prompt evaluation by a healthcare provider. This frequency is a widely accepted guideline for when a mother should contact her healthcare provider. Option B) Fewer than 20 movements in 1 hour sets a higher threshold than the standard recommendation, potentially delaying necessary medical intervention. Option C) No movement in 4 hours poses a risk by allowing too much time to pass without monitoring fetal activity. Option D) No movement after eating a meal is not a standard criterion for assessing fetal well-being and may lead to unnecessary concerns or delays in seeking medical attention when needed. Educationally, it is important for nurses to teach pregnant clients the importance of regular kick counts, when to perform them, and what to do if there are concerning changes in fetal movement. This empowers clients to be proactive in monitoring their baby's health and seeking timely medical assistance when needed.

Correct Answer: C

Rationale: In postpartum education, it is crucial to emphasize the importance of recognizing warning signs that could indicate a potential complication. In this scenario, the correct answer is C) Severe headache and blurred vision, which should be reported immediately. These symptoms could be indicative of conditions such as preeclampsia or eclampsia, which are serious and require prompt medical attention to prevent harm to the mother. Option A) Increased lochia on standing is a common postpartum occurrence, especially if the client has been active. It is important to educate clients on the expected amount and color of lochia, but increased flow upon standing alone is not typically a cause for immediate concern. Option B) Breast tenderness and fullness are common postpartum symptoms related to breastfeeding. While these symptoms should be addressed to ensure proper latch and milk supply, they do not typically indicate a serious complication that requires immediate reporting. Option D) Mild swelling in the feet is a common postpartum symptom due to fluid shifts in the body. While some swelling is expected, sudden severe swelling accompanied by other symptoms like headache and blurred vision could be concerning. However, mild swelling alone is not an immediate cause for alarm. Educational context is crucial in helping postpartum clients differentiate between normal postpartum experiences and potential warning signs. By explaining the rationale behind the correct answer and why the other options are not immediate concerns, nurses can empower clients to advocate for their health and seek timely medical intervention when necessary.