A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting; and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?

Hyperemesis gravidarum

Preterm labor

Hydatidiform mole

Threatened abortion

Answer and Explanation

The Correct Answer is C

A. Hyperemesis gravidarum: Hyperemesis gravidarum is severe nausea and vomiting that leads to dehydration, electrolyte imbalances, and weight loss. However, this client has not experienced weight loss, and the prune-colored discharge is not a sign of this condition.

B. Preterm labor: Preterm labor typically involves contractions and cervical dilation. At 4 months, preterm labor is not likely, and the prune-colored discharge and larger-than-expected fundal height are not signs of preterm labor.

C. Hydatidiform mole: A hydatidiform mole (molar pregnancy) is characterized by abnormal placental development, leading to larger-than-expected fundal height, continued nausea and vomiting, and prune-colored vaginal discharge due to bleeding from the uterus. These findings align with the client's symptoms.

D. Threatened abortion: A threatened abortion involves vaginal bleeding in early pregnancy without the expulsion of the fetus. This condition is typically associated with cramping and a smaller fundal height, which is not seen in this case.

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Correct Answer is A

Explanation

A. "You will need an immunization following delivery." A negative rubella titer indicates the client is not immune to rubella. Since the rubella vaccine is a live vaccine, it cannot be given during pregnancy but should be administered postpartum to protect the client and future pregnancies.

B. "You are immune to rubella." A negative rubella titer indicates the client is not immune to rubella.

C. "I will administer the rubella immunization to you today." The rubella vaccine cannot be administered during pregnancy due to the risk of congenital rubella syndrome in the fetus, as it is a live attenuated vaccine.

D. "You had the rubella infection as a child." A negative rubella titer means there is no immunity, so the client likely has not had the rubella infection or the immunity has waned.

Correct Answer is ["0.5"]

Explanation

The ordered dose is 1 mg, and the concentration available is 1 mg per 0.5 mL. Therefore, the nurse will administer 0.5 mL per dose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client?

Correct Answer is A

Explanation

. A nurse is preparing to administer vitamin K 1mg IM to a newborn. Available is vitamin K injection 1 mg/0.5 mL How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

A nurse is caring for a client who tells the nurse that she thinks she might be pregnant because she is able to feel the baby move. Which of the following statements should the nurse make?

A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis. The client needs an amniocentesis to determine which of the following findings?

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives?

A nurse is reinforcing teaching with a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSAFP) determination. Which of the following information should the nurse include?

A nurse in a prenatal clinic is determining a client’s estimated date of delivery using Naegels rule. The first day of her last menstrual period was May 4. Which of the following dates should the nurse tell the client is her estimated date of delivery?

A nurse is assisting in the plan of care for a client who is pregnant and has phenylketonuria (PKU). Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?