NR-327 Maternal-Child Nursing - Set 2 - Part 3

Correct Answer: Chronic hypertension predating the pregnancy

Hypertension documented before conception or before twenty weeks is chronic. She needs a safe agent such as labetalol, low-dose aspirin for prevention, and watching for superimposed preeclampsia later in the pregnancy. Option b is incorrect because the gestational label is reserved for pressures that first rise after the twentieth week. Readings that existed before conception cannot have been caused by this pregnancy, whatever the trimester happens to be. Option c is incorrect because preeclampsia is defined by new hypertension arising after the twentieth week. A client with pressures already high at ten weeks does not meet the timing requirement, and no proteinuria was described. Option d is incorrect because no such category exists in the current classification scheme. Four disorders are recognized, and inventing a transient early form would delay the medication review this client needs for her long-standing disease.

Correct Answer: Brisk patellar reflexes with sustained clonus

Hyperreflexia with clonus reflects cerebral irritability from vasospasm and edema, and any clonus is abnormal. Paired with facial and hand swelling, it points toward preeclampsia rather than the dependent swelling common in late pregnancy. Option a is incorrect because gravity explains swelling that settles in the ankles and eases with rest. Nearly every pregnant client develops it in the third trimester, so it carries no weight in this decision. Option b is incorrect because backache traces to the shifting center of gravity and to relaxin loosening the pelvic joints. Musculoskeletal discomfort that changes with position has no link to endothelial injury or vasospasm. Option c is incorrect because estrogen-driven mucosal congestion produces a stuffy nose from early pregnancy onward. A symptom that has been present for months cannot mark the new onset of a hypertensive disorder.

Correct Answer: The fetal chromosomes and the alpha fetoprotein level

Between fifteen and twenty weeks the fluid is drawn for karyotype and for alpha fetoprotein with acetylcholinesterase, so the study answers both a chromosome question and a neural tube question at once. Option a is incorrect because that ratio measures lung maturity and is requested only in the third trimester, when early birth is being weighed. At seventeen weeks the lungs have barely begun making surfactant. Option b is incorrect because fluid volume is judged by ultrasound, not by sampling. The sonographer measures the deepest pocket before the needle goes in, and removing a small amount for study says nothing about cushioning. Option d is incorrect because surfactant testing answers a delivery timing question late in pregnancy. Phosphatidylglycerol and lamellar body counts are ordered when a preterm birth is planned, which has nothing to do with a genetic screen.

Correct Answer: Obtaining an ultrasound to confirm dates and number

Most elevated results turn out to be dating errors or twins rather than defects. Ultrasound settles gestational age, counts fetuses and checks viability, so it comes before any invasive step is discussed. Option a is incorrect because reaching for a needle skips the explanation that fits most of these results. Amniocentesis for fluid alpha fetoprotein and acetylcholinesterase follows only if the scan confirms correct dates and a single fetus. Option b is incorrect because a second sample would be interpreted against the same uncertain gestational age. Waiting two weeks also pushes the client past the optimal window for further evaluation without adding useful information. Option c is incorrect because counseling is valuable but premature while the simplest explanations remain untested. A scan showing twins or a pregnancy further along than recorded ends the concern without any referral at all.

Correct Answer: Turn the client onto her left side

Side-lying keeps secretions out of the airway and lifts the uterus off the great vessels, so both the client and the fetus are protected while the convulsion runs its course. Option a is incorrect because forcing anything between clenched teeth breaks them and can push fragments into the pharynx. Airway equipment stays ready for use after the movements stop, not during the tonic-clonic phase itself. Option c is incorrect because holding the limbs still generates the fractures and soft tissue damage it is meant to prevent. Safety comes from padded rails, a lowered bed and clearing hard objects away. Option d is incorrect because the client must never be left alone during a convulsion. Help is summoned by calling out or using the call light while the nurse stays at the bedside protecting her.

Correct Answer: A steady trickle of clear fluid from the vagina

Continuous clear fluid points to a hole in the membranes. Leakage after the needle threatens the pregnancy through infection and cord compression, so she is seen at once rather than watched at home. Option b is incorrect because brief cramping is expected once the uterus has been entered. The reportable version is persistent contractions or severe pain that does not settle, and this discomfort resolved with a short rest. Option c is incorrect because bruising marks the small vessel injury any needle can cause. Redness spreading outward, drainage or rising pain would suggest infection, and none of those accompany a simple discolored patch. Option d is incorrect because fatigue follows a day of rest and an anxious appointment. Instructions after the procedure call for exactly that quiet, so tiredness fits the plan rather than signaling a complication.

Correct Answer: An Rh negative mother with an Rh positive newborn

Rh immune globulin is given only when an Rh negative mother has delivered an Rh positive newborn, because fetal cells carrying the D antigen are what would otherwise sensitize her immune system. Option a is incorrect because a mother who already carries the D antigen cannot be sensitized against it. Her own red cells are Rh positive, so exposure to Rh negative fetal blood provokes no anti D response. Option c is incorrect because both mother and newborn share the same D antigen status here, leaving nothing foreign for maternal antibodies to target. Prophylaxis in this pair would give the client an injection with no benefit. Option d is incorrect because an Rh negative newborn presents no D antigen to the maternal circulation. Cord blood typing is done precisely to identify this situation, and the postpartum dose is then withheld.

Correct Answer: Congenital cytomegalovirus caught from young children

Cytomegalovirus is the most common congenital infection, spreads in the saliva and urine of toddlers, and typically shows up as progressive sensorineural hearing loss with microcephaly in an otherwise well appearing newborn. Option a is incorrect because rubella brings cataracts and cardiac defects such as patent ductus arteriosus alongside the deafness. Immunity is also checked at the first prenatal visit, which makes an unrecognized case unlikely. Option b is incorrect because toxoplasmosis classically produces chorioretinitis, hydrocephalus and intracranial calcifications rather than isolated hearing loss. Nothing in this history points toward cat feces, garden soil or undercooked meat. Option d is incorrect because a syphilitic newborn shows snuffles, a rash across the palms and soles, hepatosplenomegaly and bone lesions. Universal screening at the first visit also catches maternal infection before birth.

Correct Answer: "My dose will likely rise, with blood levels checked regularly."

Levothyroxine requirements climb early in pregnancy, with the dose usually raised about a quarter, and thyroid stimulating hormone rechecked every four to six weeks. The fetus depends on maternal hormone during the first trimester. Option a is incorrect because stopping replacement therapy is the one thing this client must never do. Untreated hypothyroidism raises the risk of miscarriage, preeclampsia and lasting harm to fetal brain development. Option b is incorrect because iron and calcium in prenatal vitamins bind levothyroxine and cut absorption. The tablet belongs on an empty stomach, separated from those supplements by roughly four hours. Option c is incorrect because an unchanged dose cannot meet the extra demand created by rising thyroid binding globulin and fetal need. Serial testing exists precisely so the prescription can be adjusted upward.

Correct Answer: Reassure the client that these effects are expected

Flushing, warmth, sweating, dry mouth and mild nausea are ordinary responses to the loading dose. Naming them as expected keeps the client calm and separates them from the reflex and respiratory changes that signal toxicity. Option b is incorrect because halting therapy for a harmless warm sensation leaves the client unprotected against eclamptic seizures. The infusion is stopped for absent reflexes, slowed breathing, oliguria or a falling level of consciousness. Option c is incorrect because the antidote belongs at the bedside unopened until true toxicity appears. Giving calcium now would reverse the very neuromuscular effect that is protecting this client from a seizure, with no benefit. Option d is incorrect because cutting the rate without an order drops the serum level below the range that prevents seizures. Expected side effects call for explanation and continued hourly monitoring rather than a change in dose.