ATI RN
Complications in Early Pregnancy Questions
Question 1 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.
Question 2 of 5
The nurse is caring for a client with severe hyperemesis gravidarum. She is 10 weeks gestation and has a 10% weight loss. The client is being admitted for fluid and electrolyte replacement. The nurse is aware it is important to check which deficiency that puts the client at risk for Wernicke’s encephalopathy?
Correct Answer: C
Rationale: The correct answer is C: Thiamine. In severe hyperemesis gravidarum, excessive vomiting can lead to thiamine deficiency, increasing the risk of Wernicke's encephalopathy, a neurological disorder. Thiamine is essential for the brain's energy metabolism. Without adequate thiamine, neurological symptoms such as confusion, memory issues, and ataxia can arise. Folic acid (choice A) is important for neural tube development but not directly related to Wernicke's encephalopathy. Vitamin D (choice B) deficiency can lead to various issues but is not associated with Wernicke's encephalopathy. Glucose (choice D) is a source of energy but does not directly influence thiamine deficiency and Wernicke's encephalopathy.
Question 3 of 5
The doctor suspects that the client is in preterm labor. Which symptom is consistent with this diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Abdominal cramping and lower back pain. This symptom is consistent with preterm labor as it indicates contractions and possible cervical changes. Severe pain in the lower quadrant (A) is more likely related to other conditions like ectopic pregnancy. Severe pain and hard abdomen to palpation (B) may suggest a more acute issue like placental abruption. Painless vaginal bleeding (C) is typically seen in conditions like placenta previa. Therefore, choice D is the most indicative of preterm labor based on the symptoms presented.
Question 4 of 5
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.
Question 5 of 5
A client who is 30 weeks pregnant comes into the labor and delivery unit complaining of having a gush of fluid come from her vagina. Which complication is this client at risk for?
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client at 30 weeks experiences a gush of fluid from the vagina, it may indicate ruptured membranes leading to amniotic fluid leakage. This can lead to a decrease in amniotic fluid volume, potentially causing fluid volume deficit for both the mother and the fetus. This can result in complications such as preterm labor, infection, and fetal distress. The other choices are incorrect because: A: Infection is a potential risk due to the ruptured membranes, but the immediate concern is fluid volume deficit. C: Hypotension is not directly related to the scenario described. D: Decreased urinary output is not a typical immediate concern with ruptured membranes; rather, the focus should be on assessing for signs of fluid loss and ensuring hydration.