OB HESI EAQ - At Risk
A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life? 2:1 1:1 1:4 3:4
2:1
In the second hour after a client gives birth, her uterus is found to be firm, above the level of the umbilicus, and to the right of midline. What is the appropriate nursing intervention at this time? Checking for signs of retained placental fragments Massaging the uterus to prevent hemorrhage Assisting the client to the bathroom to empty her bladder Telling the client that this is a sign of uterine stabilization
Assisting the client to the bathroom to empty her bladder
During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of large and painful varicose veins. In light of this information, what should the nurse's assessment include? Monitoring daily clotting times Assessing for peripheral pulses Monitoring daily hemoglobin values Assessing for signs of thrombophlebitis
Assessing for signs of thrombophlebitis
A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? Face Brow Breech Shoulder
Breech
The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? Calling the primary healthcare provider Checking the client's reflexes Determining the client's blood type Administering the prescribed intravenous (IV) normal saline
Checking the client's reflexes
A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? Providing a plastic airway Controlling external stimuli Having emergency equipment available Keeping calcium gluconate at the bedside
Controlling external stimuli
A client has delivered her infant via cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day? Providing oxygen therapy Administering pain medication Encouraging frequent ambulation Recommending an increase in oral fluids
Encouraging frequent ambulation
A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? Taking exogenous insulin stimulates fetal growth. Consuming more calories covers the insulin secreted by the fetus. Extra circulating glucose causes the fetus to acquire fatty deposits. Fetal weight gain increases as a result of the common response of maternal overeating.
Extra circulating glucose causes the fetus to acquire fatty deposits.
A client's membranes ruptured 20 hours before admission. The client was in labor for 24 hours before giving birth. For which postpartum complication is this client at risk? Infection Hemorrhage Uterine atony Amniotic fluid embolism
Infection
A client in labor is admitted to the birthing unit 20 hours after her membranes have ruptured. Which complication should the nurse anticipate when assessing the character of the client's amniotic fluid? Cord prolapse Placenta previa Maternal sepsis Abruptio placentae
Maternal sepsis
An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the fetus is in what position? Breech Transverse Occiput anterior Occiput posterior
Occiput posterior
While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? True labor Placenta previa Partial abruptio placentae Abdominal muscular injury
Partial abruptio placentae
A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blisterlike lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the primary healthcare provider and received prescriptions, what is the priority nursing action? Beginning the intravenous (IV) antibiotic Preparing for a cesarean birth Taking a smear of the lesions for testing Documenting the need for double gloving
Preparing for a cesarean birth
A client is admitted with a diagnosis of preeclampsia. Which significant clinical finding does the nurse expect when reviewing the client's history? Proteinuria Tachycardia Increased serum glucose Tonic-clonic movements
Proteinuria
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? The client does not have an infection. The donor blood is free of bloodborne pathogens. The nurse should have worn gloves for self-protection. The nurse was skilled enough to prevent exposure to the blood.
The nurse should have worn gloves for self-protection.
A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect? Missed abortion Inevitable abortion Incomplete abortion Threatened abortion
Threatened abortion
The nurse is caring for a client who has been admitted with a tentative diagnosis of placenta previa. What procedure does the nurse anticipate? Laparoscopy Nonstress test Amniocentesis Ultrasound examination
Ultrasound examination
The nurse is caring for a woman who just had a positive contraction stress test (CST). Which complication of pregnancy is of most concern when there is a positive CST? Preeclampsia Placenta previa Imminent preterm birth Uteroplacental insufficiency
Uteroplacental insufficiency
A client identified as having a high-risk pregnancy is about to undergo a contraction stress test (CST). Which factor would compel the nurse to question this prescription? Blurred vision Vaginal bleeding Sickle cell disease Increasing hypertension
Vaginal bleeding
During a follow-up appointment, a client at 21 weeks' gestation is diagnosed with hyperemesis gravidarum. The client says, "Why is this happening to me? I don't know whether I can go on like this." What is the ideal response by the nurse? "Are you saying that you want to schedule an abortion?" "This must be physically and emotionally challenging for you." "We're doing the best we can here, so please be patient with us." "There are dietary changes and medications available that can ease the nausea."
"This must be physically and emotionally challenging for you."
What is the primary responsibility of a nurse teaching the pregnant adolescent? Instructing her about the care of an infant Informing her of the benefits of breast-feeding Advising her to watch for danger signs of preeclampsia Encouraging her to continue regularly scheduled prenatal care
Encouraging her to continue regularly scheduled prenatal care
A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if accelerations of the fetal heart rate occur with fetal movement, this probably indicates what? Fetal well-being Fetal head compression Uteroplacental insufficiency Umbilical cord compression
Fetal well-being
A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? Gravida III with twins Gravida V with endometriosis Gravida II who had a 9-lb baby Gravida I who has had an intrauterine fetal death
Gravida I who has had an intrauterine fetal death