A 32 year-old G3P2 client is returning for her prenatal visit at 28 weeks.Her prenatal labs on record thus far are as follows: Type & Rh =A negative.
Antibody screen normal.
RPR = negative.
HIV = negative.
Rubella titer 1:16. Cervical smears negative for Gonorrhea & Chlamydia.
Hemoglobin/hematocrit = 11.0 mg/dl and 35%. Gestational diabetes glucose challenge test (GCT) Screen 26 wks = 120.
Urine analysis positive for leukocytes.
Today her plan of care should include which of the following: (Select all that apply)
Administer Rubella vaccine IM.
Instruct client on signs and symptoms of preterm labor.
Administer Rhogam IM.
Obtain a clean catch urine culture.
Order a 3-hour diagnostic glucose tolerance test.
Administer a blood transfusion.
Correct Answer : B,C,D,E
Choice A rationale
Rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome in the fetus. It should be administered postpartum if the client is non-immune.
Choice B rationale
Preterm labor is a concern at 28 weeks' gestation. Educating the client on signs and symptoms can help in early detection and management, potentially improving outcomes for both mother and baby.
Choice C rationale
Rh-negative mothers with a negative antibody screen should receive Rhogam at 28 weeks to prevent Rh sensitization. This is crucial to avoid hemolytic disease of the newborn in future pregnancies.
Choice D rationale
A positive urine analysis for leukocytes indicates a possible urinary tract infection. A clean catch urine culture is needed to identify the causative organism and guide appropriate antibiotic therapy.
Choice E rationale
The glucose challenge test result of 120 at 26 weeks is within normal limits, but a 3-hour diagnostic glucose tolerance test may be ordered if there's a high index of suspicion for gestational diabetes or other risk factors.
Choice F rationale
A blood transfusion is not indicated as the hemoglobin/hematocrit levels (11.0 mg/dl and 35%) are within acceptable limits for pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Quickening, the first movements of the fetus felt by the mother, typically occurs between 18-20 weeks gestation. At 18 weeks, it's likely the mother will feel a fluttering sensation soon.
Choice B rationale
While fetal movements can sometimes be felt later, it's generally expected that by 18-20 weeks, movements should be noticeable.
Choice C rationale
The baby does move at 18 weeks, but the mother typically begins to feel these movements at this stage, known as quickening.
Choice D rationale
Suggesting the mother should have felt movement by now could cause unnecessary anxiety. Most women feel their baby's movements between 18-20 weeks. .
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Weight loss of 2.8 kg (6.2 lb): Consistent - Significant weight loss is a classic symptom of hyperemesis gravidarum. The client has lost more than 5% of her pre-pregnancy weight, which is concerning and supports this diagnosis.
Hematocrit: 30%: Not Consistent - Hematocrit measures the proportion of red blood cells in the blood. In hyperemesis gravidarum, the hematocrit may be elevated due to dehydration, not decreased. Therefore, this value is not consistent with the typical presentation.
Vaginal spotting: Not Relevant - While vaginal spotting can be concerning in pregnancy, it is not a specific sign of hyperemesis gravidarum and does not directly relate to the diagnosis of severe nausea and vomiting.
Heart rate: 110/min: Consistent - Tachycardia (elevated heart rate) can occur due to dehydration and the body’s response to prolonged vomiting, making this finding consistent with hyperemesis gravidarum.
BUN: 28 mg/dL: Consistent - Blood urea nitrogen (BUN) is elevated in this client, suggesting dehydration. Dehydration is a common complication of hyperemesis gravidarum due to persistent vomiting and poor oral intake.
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