The nurse is caring for a client with gestational hypertension. What symptom should be reported immediately?

Correct Answer: A

Rationale: In the context of caring for a client with gestational hypertension, it is crucial for the nurse to be vigilant for signs of worsening condition that could indicate a progression to a more serious complication like preeclampsia. The symptom that should be reported immediately in this scenario is A) Headache unrelieved by acetaminophen. Severe headaches can be a warning sign of worsening hypertension or preeclampsia, which can lead to serious complications for both the mother and baby. Failure to address this symptom promptly could result in significant harm. Option B) Slight swelling of the hands is a common symptom in pregnancy and may not necessarily indicate a serious problem unless it is severe and accompanied by other concerning symptoms. Option C) Mild nausea after eating is also a common occurrence during pregnancy and is not typically a cause for immediate concern unless it is persistent, severe, or accompanied by other symptoms. Option D) Fatigue at the end of the day is a common symptom in pregnancy and is not typically indicative of a serious complication like preeclampsia. Educationally, it is important for nurses to understand the significance of monitoring for signs and symptoms of gestational hypertension and preeclampsia, as these conditions can have serious implications for both the mother and baby if not identified and managed promptly. Nurses should be equipped to differentiate between normal pregnancy symptoms and those that require immediate attention to provide safe and effective care to pregnant clients.

Correct Answer: B

Rationale: In the context of caring for a client with suspected placenta previa, the priority nursing intervention is to monitor fetal heart rate and maternal vital signs (Option B). This is crucial because placenta previa can lead to significant maternal hemorrhage and compromise fetal well-being due to poor placental perfusion. Monitoring fetal heart rate and maternal vital signs allows the nurse to assess for any signs of distress in both the mother and the baby. Any sudden changes in vital signs or fetal heart rate may indicate a worsening condition and prompt the need for immediate intervention or delivery. Performing a sterile vaginal examination (Option A) is contraindicated in placenta previa as it can lead to further disruption of the placenta and increase the risk of hemorrhage. Administering oxytocin to stop bleeding (Option C) is not appropriate without a clear understanding of the cause of bleeding, as oxytocin can exacerbate bleeding in placenta previa. Encouraging the client to ambulate (Option D) is not a priority when there is a risk of significant bleeding and compromised fetal well-being. In an educational context, understanding the priority interventions in obstetric emergencies like placenta previa is essential for nurses to provide safe and effective care to pregnant clients. Prioritizing assessments and interventions based on the client's condition can significantly impact outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In the context of maternal health during pregnancy, anemia is a common concern due to the increased demands on the mother's body for adequate blood supply to support both her and the developing fetus. The correct answer, option A, states a hemoglobin level of 10 g/dL, which supports the diagnosis of anemia. Hemoglobin is a protein found in red blood cells responsible for carrying oxygen throughout the body. During pregnancy, a hemoglobin level below 11 g/dL is considered indicative of anemia due to the expansion of plasma volume, which can dilute the concentration of red blood cells. Therefore, a hemoglobin level of 10 g/dL at 20 weeks' gestation raises suspicion for anemia. Analyzing the incorrect options: B) Platelet count of 150,000 mm3: Platelets are involved in blood clotting, not in diagnosing anemia. C) Hematocrit of 40%: While hematocrit measures the proportion of red blood cells in the blood, a specific hemoglobin level is more indicative of anemia. D) White blood cell count of 8,000 mm3: White blood cells are part of the immune system and are not directly related to diagnosing anemia. Educationally, understanding the importance of interpreting lab values in the context of pregnancy helps nurses provide optimal care to both the mother and the fetus. Recognizing the significance of hemoglobin levels in assessing for anemia during pregnancy is crucial for timely intervention and management to promote positive maternal and neonatal outcomes.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, the priority intervention when assessing a client in labor with variable decelerations on the fetal monitor is to reposition the client (Option B). Repositioning the client, specifically onto their left side, helps to alleviate pressure on the vena cava, improving fetal oxygenation and potentially resolving the decelerations. Increasing the oxytocin infusion (Option A) can actually worsen variable decelerations by intensifying contractions, further compromising fetal oxygenation. Administering oxygen at 10 L/min (Option C) is generally a good intervention, but repositioning takes precedence in this scenario. Notifying the healthcare provider (Option D) is important, but it is not the immediate priority over repositioning the client to address the variable decelerations. Educationally, this rationale highlights the critical thinking skills needed in pharmacology and maternal newborn care. Understanding the physiological effects of different interventions is crucial in prioritizing care for both the mother and the unborn baby. By repositioning the client, nurses can actively contribute to improving fetal well-being during labor and delivery.

Correct Answer: A

Rationale: In the context of maternal fetal health, educating clients about kick counts is crucial for monitoring fetal well-being. The correct answer is A) Fewer than 10 movements in 2 hours because it aligns with the standard recommendation of feeling at least 10 movements within a 2-hour period. This frequency indicates adequate fetal activity and suggests a healthy baby. Contacting the healthcare provider in this scenario allows for prompt evaluation and intervention if needed. Option B) Fewer than 5 movements in 1 hour sets a threshold that is too low and may lead to unnecessary anxiety and frequent calls to the healthcare provider. It does not align with the standard kick count recommendations. Option C) No movements after drinking juice is not a reliable indicator of fetal well-being. Fetal movements can vary based on various factors, and the response to ingesting juice may not always be immediate or consistent. Option D) No movements for 12 hours is too long to wait before seeking medical attention. Delaying contact with the healthcare provider in such a situation could pose risks to the fetus if there is an issue with decreased fetal movement. Educationally, understanding the significance of kick counts empowers pregnant individuals to actively participate in monitoring their baby's health. By providing accurate information on when to contact the healthcare provider, nurses can help ensure timely interventions and promote positive maternal and newborn outcomes.