Custom: Maternal Newborn AP Problems

A client has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. Hyperbilirubinemia occurs with Rh incompatibility between client and fetus because A. the client's blood does not contain the Rh factor, so she produces anti Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus C. The client has a history of previous jaundice caused by a blood transfusion, affecting the fetus through the placenta D. The newborn develops a congenital defect shortly after birth that causes the destruction of red blood cells

A.

A nurse is providing teaching to the mother of an infant born small for gestational age. Which of the following should the nurse include as a cause of this condition? A. Placental insufficiency B. Maternal Obesity C. Primipara D. Perinatal asphyxia

A. Placental insufficiency can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities

A nurse is admitting a client who is at 10 weeks gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following actions should the nurse include in the client's plan of care? A. Prepare to administer oxygen B. Determine the amount and type of vaginal bleeding C. Instruct the client in appropriate birth control methods D. Keep the client on bed rest

B Assessment first. It is important for the nurse to note the amount and type of bleeding and to monitor the client for indications of excessive blood loss.

A client comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? A. Chvostek's sign B. Cullen's sign C. Chadwick's sign D. Goodell's sign

B Chvostek's sign is a response of facial twitching when the examiner taps the client's face over the facial nerve, caused by hypocalcemia Chadwick's sign is a change in the color of the vagina from pink to purplish, and a probable finding during pregnancy Goodell's sign is a softening of the cervix, and a probable finding during pregnancy

A nurse in a prenatal clinic is caring for a client who is at 38 weeks gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine A. Fetal lung maturity B. Location of the placenta C. Viability of the fetus D. The biparietal diameter

B Painless, spontaneous vaginal bleeding may indicate that the client has placenta previa, a condition in which the placenta implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. Ultrasound is required to show the location of the placenta, help determine what sort of delivery the client requires, and how emergent it is

A client is admitted to the maternity who is 38 weeks gestation and experiencing polyhydramnios. The nurse understands that this diagnosis means that A. There is the normal amount of amniotic fluid, thinner in volume B. Less than normal amount of amniotic fluid is present C. An excessive amount of amniotic fluid is present D. A leak is causing fluid to accumulate outside the amniotic sac

C

A nurse is admitting a client who is at 30 weeks gestation and is in preterm labor. The provider prescribes betamethasone (Celestone) stat. When the client asks the nurse about the purpose of the medication, the nurse should reply that it will help A. Stop preterm labor contractions B. Halt cervical dilation C. Boost fetal lung maturity D. increase the fetal heart rate

C

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client tells the nurse that the provider said he cannot examine her internally and the client asks the nurse why. The nurse should explain that this is primarily because an internal examination could A. introduce infection B. initiate preterm labor C. cause profound bleeding D. rupture the fetal membranes

C "Pelvic rest" is essential for clients who have placenta previa; no vaginal examinations, no douching, and no vaginal intercourse. This is because any pressure on the placenta could cause its premature separation and life-threatening hemorrhage

A nurse is assessing a client who is pregnant for pre-eclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluat9ion for this disorder? A. increased urine output B. Vaginal discharge C. Elevated bp D. joint pain

C Hypertension is one of the cardinal symptoms of pre-eclampsia along with excessive weight gain, edema, and albumin in the urine.

A nurse is caring for a client who is having a nonstress test performed. The FHR is 130 to 150 bpm, but there has been no fetal movement for 15 min. Which of the following is an appropriate nursing intervention? A. Immediately report the situation to the client's provider and prepare the client for induction of labor B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring C. Offer the client a snack of orange juice and crackers D. Turn the client on her left side

C. This fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mom a snack will promote fetal movement

A nurse in the antepartum unit is caring for a client who is at 36 weeks gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta Previa B. Prolapsed cord C. Ruptured ovarian cysts D. Abruptio placentae

D Cardinal signs and symptoms of abruptio placentae include a rigid board-like abdomen, severe pain, and heavy vaginal bleeding

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks gestation with a diagnosis of pregnancy induced hypertension. Which of the following findings should the nurse identify as inconsistent with the admitting diagnosis? A. 1+ pitting sacral edema B. 3+ protein in the urine C. Blood pressure 148/98 mm Hg D. Deep tendon reflextes of +1

D. Deep tendon reflexes of +1 are decreased, in PIH they would be increased.

A nurse is admitting a client who is at 38 weeks of gestation and has severe pre-eclampsia. When assessing the client, the nurse should expect which of the following findings? A. Tachycardia B. Diplopia C. Polyuria D. Headache

D. Severe pre-eclampsia causes headache, blurred vision, irritability, nausea, vomiting, hypertension, proteinuria, and edema.

A nurse in a prenatal clinic is assessing a client who is suspected of having a hydatidform mole. Which of the following findings should the nurse expect to observe in this client? A. rapidly dropping human chorionic gonadotropin (hCG) levels B. Bright red vaginal bleeding C. Fetal heart rate irregularities D. Excessive uterine enlargement

D. A hydatidiform mole is a rare tumor that may form inside the uterus at the beginning of a pregnancy. In very rare cases, after an egg is fertilized, a hydatidiform mole results from over-production of the tissue that would normally develop into the placenta. These tissues develop into a mass. A rapidly enlarging uterus is a classic characteristic of a rapidly growing hydatidiform mole. It is often accompanied by severe nausea and vomiting, elevated hCG levels, hyperthyroidism symptoms, and sings of pregnancy-induced hypertension in the first trimester.