• Frequent urination: This is more likely to be associated with a UTI, as frequent urination is a common symptom of UTIs.
• Low back pain: This can be associated with both preterm labor and a UTI. Low back pain can be a sign of labor, and it can also be a symptom of a UTI.
• Temperature of 38.3°C (101°F): This is more likely to be associated with a UTI, as fever is a common symptom of infections, including UTIs.
• Strong urge to push: This is more likely to be associated with preterm labor, as an urge to push can be a sign of labor.
• Contractions every 1.5 minutes: This is more likely to be associated with preterm labor, as frequent contractions are a sign of labor.
• Pain level of 8 on a scale of 0 to 10: This can be associated with both preterm labor and a UTI. Severe pain can be a sign of labor, and it can also be a symptom of a UTI. Please note that these are potential associations and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

• Increase the oxytocin infusion to 13 mU/min: This is an anticipated action. The client’s contractions are becoming more frequent and intense, and her cervix is dilating and effacing. Increasing the oxytocin infusion can help to further progress labor.
• Place client in a side-lying position: This is an anticipated action. The side-lying position can help to improve maternal and fetal circulation and can also help to alleviate back pain.
• Initiate bolus of primary IV fluids: This is an anticipated action. The client is in labor and may not be able to consume adequate fluids orally. Providing IV fluids can help to prevent dehydration.
• Apply oxygen at 10 L/min via venturi mask: This is a nonessential action. The client’s respiratory rate and oxygen saturation are within normal limits, and she is not reporting any difficulty breathing.
• Perform sterile vaginal exam: This is an anticipated action. Regular vaginal exams are necessary to assess the progress of labor, including changes in cervical dilation, effacement, and fetal station.
• Assign a Bishop score: This is a nonessential action. The Bishop score is typically used to evaluate the readiness of the cervix for induction of labor. As the client is already in labor and her cervix is dilating and effacing, assigning a Bishop score is not necessary at this time.
• Perform an amniotomy: This is a nonessential action. An amniotomy (artificial rupture of membranes) can be used to induce or augment labor, but it is not necessary if labor is progressing normally, as it appears to be in this client. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

Choice A rationale: Conducting a non-stress test twice per week is a common practice for pregnant women who are at high risk, and this client is considered high risk due to her history of gestational diabetes and the fact that her two previous newborns weighed over
4.5 kg. A non-stress test is a simple, noninvasive test that checks the baby’s heart rate and response to movement. It’s called a “non- stress” test because it causes no stress to the baby. The test usually takes about 20 to 30 minutes. The mother lies on her left side, and a belt with a sensor that can detect the baby’s heartbeat is placed around her abdomen. The baby’s heart rate is expected to increase with each movement, and this is a sign that the baby is healthy and getting enough oxygen. If the baby’s heart rate does not increase with movement, it may mean that the baby is not getting enough oxygen, which could be a sign of a problem.

Choice B rationale: Monitoring blood glucose levels once daily is crucial for this client due to her history of gestational diabetes and current elevated fasting blood glucose level. Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. It may precede development of type 2 DM. Self-monitoring of blood glucose levels in gestational diabetes is considered a cornerstone of management to improve maternal and neonatal prognosis. It allows pregnant women to evaluate their individual response to therapy and assess whether glycemic targets are being achieved. This can help prevent complications related to gestational diabetes, such as macrosomia (a high birth weight), hypoglycemia in the newborn, and pre- eclampsia in the mother.

Choice C rationale: Referring the client to a dietitian for nutritional counseling is an important step in managing her gestational diabetes. Diet plays a crucial role in managing blood glucose levels during pregnancy. A dietitian can provide a personalized meal plan that includes the right amount of carbohydrates, protein, and fat for the client. The meal plan will also take into account the client’s food preferences, lifestyle, and weight gain goals during pregnancy. Nutritional counseling can help the client understand how different foods affect her blood glucose levels and how to make healthy food choices that will benefit both her and her baby.

Choice D rationale: Instructing the client to refrain from physical activity is not a recommended action. Physical activity is generally beneficial for pregnant women, including those with gestational diabetes. Regular physical activity can help lower blood glucose levels, reduce insulin resistance, and manage weight gain during pregnancy. However, the type and intensity of physical activity should be appropriate for the client’s fitness level and pregnancy stage, and any physical activity should be done under the guidance of a healthcare provider.

Choice E rationale: Increasing caloric intake to support fetal growth is not necessarily a recommended action for this client. While it’s true that pregnant women need additional calories to support fetal growth, this must be balanced with the need to manage blood glucose levels in the case of gestational diabetes. Consuming too many calories, particularly in the form of carbohydrates, can lead to high blood glucose levels. Instead, the focus should be on consuming a balanced diet that includes a variety of nutrients to support fetal growth.

Choice A rationale: A headache that lasts for 2 days and is not relieved by Tylenol is a concerning symptom in a pregnant client. This could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby. Severe headaches are a common symptom of preeclampsia and should be reported to the healthcare provider immediately.

Choice B rationale: Blurred vision and dizziness are also symptoms of preeclampsia. These symptoms occur as a result of changes in the blood vessels in the brain due to high blood pressure. The brain relies on a healthy blood supply to function properly, and any disruption to this can lead to symptoms such as blurred vision and dizziness. These symptoms should be reported to the healthcare provider immediately as they may indicate a need for immediate treatment or monitoring.

Choice C rationale: While swelling of the feet is common in pregnancy due to fluid retention and increased blood flow, it is not typically a symptom that needs to be reported to the healthcare provider unless it is accompanied by other symptoms of preeclampsia or other complications. Swelling in the face and hands is more concerning than swelling in the feet.

Choice D rationale: 2+ pitting edema of the lower extremities is a sign of fluid overload in the body, which can be a symptom of preeclampsia. This should be reported to the healthcare provider as it may indicate a need for treatment or closer monitoring.

Choice E rationale: Deep tendon reflexes of 3+ and absent clonus are within normal limits for a pregnant client. Hyperreflexia (reflexes rated as 4+) and the presence of clonus could indicate neurological irritability associated with preeclampsia, but these findings are not present in this client.

Choice F rationale: Fetal heart tones of 150/min are within the normal range of 110-160 beats per minute. This is a reassuring sign and does not need to be reported to the healthcare provider.

Choice G rationale: A blood pressure of 180/99 mm Hg is significantly elevated and is a hallmark sign of preeclampsia. This should be reported to the healthcare provider immediately as it indicates severe preeclampsia, which requires immediate treatment to prevent complications such as eclampsia, placental abruption, and organ damage.

Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.

The correct answer is choice A. Drink 48 to 64 ounces of water daily.

Choice A rationale:

Drinking 48 to 64 ounces of water daily is recommended to help maintain hydration and support overall health during pregnancy, especially for those with mild preeclampsia.

Choice B rationale:

While protein intake is important, the recommended amount for pregnant women is generally higher than 40 to 90 grams per day. The exact amount can vary based on individual needs, but typically, pregnant women are advised to consume around 71 grams of protein daily.

Choice C rationale:

Limiting intake of whole grains, raw fruits, and vegetables is not recommended. These foods are rich in essential nutrients and fiber, which are beneficial for both the mother and the baby.

Choice D rationale:

Avoiding salting of foods during cooking can help manage blood pressure, but it is not the primary focus of dietary recommendations for preeclampsia. Reducing overall sodium intake is more important.

Choice A rationale
Rh(D) immunoglobulin prevents the formation of Rh antibodies in mothers who are Rh negative. If an Rh-negative mother is exposed to Rh-positive blood, as can happen during pregnancy or childbirth, her immune system may respond by making antibodies against the Rh antigen. This can cause problems in future pregnancies if the baby is Rh positive. Rh(D) immunoglobulin works by preventing the mother’s immune system from recognizing the Rh antigen, thus preventing the formation of antibodies.
Choice B rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in mothers who are Rh negative. Once antibodies have formed, they cannot be destroyed by Rh(D) immunoglobulin.
Choice C rationale
Rh(D) immunoglobulin does not prevent the formation of Rh antibodies in newborns who are Rh positive. The purpose of Rh(D) immunoglobulin is to prevent the mother from forming Rh antibodies.
Choice D rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in newborns who are Rh positive. The purpose of Rh(D) immunoglobulin is to prevent the mother from forming Rh antibodies.

Choice A rationale
Vaginal discharge, or leukorrhea, often increases during pregnancy due to higher levels of estrogen and greater blood flow to the vaginal area. It does not typically decrease before labor.
Choice B rationale
Weight gain is expected during pregnancy, but a sudden gain of 0.5 to 1.3 kg is not a typical sign that labor is about to start.
Choice C rationale
Urinary retention is not a typical sign that labor is about to start. In fact, many women find that they need to urinate more frequently as labor approaches, due to increased pressure on the bladder.
Choice D rationale
A surge of energy, often called “nesting,” can be a sign that labor is about to start. Some women experience a burst of energy and the desire to prepare their home for the baby in the days or hours before labor begins.

Step 1 is to determine the amount of heparin to administer. The client is receiving 3,800 units of heparin, and the available heparin is 5,000 units/mL.
Step 2 is to set up the calculation: (3,800 units ÷ 5,000 units/mL) = x mL.
Step 3 is to perform the calculation: x = 0.76 mL. Therefore, the nurse should administer 0.8 mL of heparin, rounded to the nearest tenth.

Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.

Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.