The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?

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Complications in Early Pregnancy Questions

Question 1 of 5

The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?

Correct Answer: D

Rationale: The correct answer is D because a urine dipstick showing protein of 3+ indicates significant proteinuria, a sign of preeclampsia in pregnancy. Preeclampsia can lead to serious complications for both the mother and the baby, such as eclampsia and fetal growth restriction. The nurse should further assess the client's blood pressure, perform additional tests for preeclampsia, and closely monitor the client's condition. Choice A: Hemoglobin and hematocrit levels are within normal range for pregnancy and do not require immediate intervention. Choice B: Blood pressure of 130/80 is slightly elevated but not concerning at this gestational age. Close monitoring is recommended. Choice C: Slight pedal swelling is common in pregnancy due to fluid retention and usually does not indicate a serious issue.

Question 2 of 5

A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?

Correct Answer: A

Rationale: The correct answer is A (Blood pressure of 155/95) because an elevated blood pressure indicates worsening pre-eclampsia. In pre-eclampsia, high blood pressure is a key indicator of worsening condition, potentially leading to eclampsia or seizures if left untreated. Choices B (Urinary output is greater than 30 mL/hr), C (Deep tendon reflexes +2), and D (Client complains of blurred vision) are not indicative of worsening pre-eclampsia. Increased urinary output, normal deep tendon reflexes, and blurred vision are common symptoms in pre-eclampsia, but they do not necessarily signify worsening of the condition.

Question 3 of 5

The nurse is caring for a woman who is suspected of having chorioamnionitis. Which of the following are risk factors for chorioamnionitis? Select all that apply.

Correct Answer: A

Rationale: The correct answer is A: Changing cat litter. Chorioamnionitis is an infection of the amniotic fluid and membranes. Changing cat litter exposes the woman to toxoplasmosis, a risk factor for chorioamnionitis. Choices B, C, and D are incorrect. Vaginal exams during labor can introduce bacteria but are not a direct risk factor. Gestational diabetes is unrelated, and preterm premature rupture of membranes can increase infection risk but is not a direct cause like exposure to toxoplasmosis.

Question 4 of 5

The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?

Correct Answer: B

Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications. Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.

Question 5 of 5

The nurse is providing discharge instructions to a 28-year-old client who received methotrexate for an ectopic pregnancy. Which should the discharge instructions include?

Correct Answer: C

Rationale: The correct answer is C. Methotrexate is a chemotherapy agent that can be harmful to others if not properly eliminated from the body. Instructing the client to flush the toilet twice after urination for the next 24 hours helps to reduce the risk of exposing others to the medication through urine. This precaution is important to prevent potential harm to others. Choices A, B, and D are incorrect: A: Taking folic acid is generally recommended to reduce side effects of methotrexate but is not directly related to the safety of others. B: While follow-up appointments are important, the immediate safety concern of methotrexate elimination is more critical. D: Resuming all activity in 48 hours may not be appropriate depending on the individual's response to methotrexate and their recovery process.

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