OB Exam 3 SPECIAL POPS 2
A client with active genital herpes has a cesarean birth. The nurse teaches the mother how to limit transmission of the virus to her newborn. The nurse concludes that the instructions have been understood when the mother states: 1 "I should avoid kissing the baby on the lips." 2 "I have to wear gloves when I'm holding the baby." 3 "I should wash my clothes and my baby's clothes separately." 4 "I have to wash my hands with soap and water before handling the baby."
"I have to wash my hands with soap and water before handling the baby."
A client asks for and receives instruction regarding birth control methods. She elects to use a diaphragm with a spermicide. What disadvantage of using a diaphragm should be explained to the client? 1 Its failure rate is 50% when it is used alone. 2 It is physically uncomfortable when in place. 3 Thrombus formation and pulmonary emboli may occur. 4 Some women find its insertion and removal inconvenient.
Some women find its insertion and removal inconvenient
A nurse is assessing a client for the potential for osteoporosis. Which factor in the client's history increases the risk for this disorder? 1 Estrogen therapy 2 Hypoparathyroidism 3 Prolonged immobility 4 Excessive calcium intake
Prolonged immobility
What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. 1 Restricting visitors 2 Limiting fluid intake 3 Preparing for a precipitate birth 4 Maintaining a quiet environment 5 Keeping magnesium gluconate at the bedside
Restricting visitors and maintaining a quiet environment
Which client is most at risk for osteoporosis? 1 A nonsmoking 60-year-old woman, 5 foot 7 inches tall and 173 lb 2 A 66-year-old white woman, 5 foot 1 inch and 100 lb, who is a paralegal 3 A 68-year-old black woman, 5 foot 5 and 140 lb, who is a retired receptionist 4 A 62-year-old woman, 5 foot 4 inches tall and 135 lb, who takes calcium carbonate daily
A 66-year-old white woman, 5 foot 1 inch and 100 lb, who is a paralegal
A client with preeclampsia who is receiving an infusion of magnesium sulfate is showing signs of toxicity. What antidote should the nurse have available at the client's bedside? 1 Calcium gluconate (Kalcinate) 2 Edetate disodium (Disodium EDTA) 3 Sodium polystyrene sulfonate (Kayexalate) 4 HydrALAZINE hydrochloride (Apresoline)
Calcium gluconate
A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity? 1 Oxygen 2 Naloxone 3 Calcium gluconate 4 Suction equipment
Calcium gluconate
What should the nurse teach a client about performing breast self-examination? 1 Compress the nipples to check for discharge. 2 Use the right hand to examine the right breast. 3 Press the palm against the breast to compress it to the chest wall. 4 Place a pillow under the shoulder opposite the side being examined
Compress the nipple to check for discharge
A pregnant client who is scheduled for a nonstress test (NST) asks a nurse how the test can show that "my baby is all right." The nurse explains that it is a way of evaluating the condition of the fetus by comparing the fetal heart rate (FHR) with: 1 Fetal gestational age 2 Fetal physical activity 3 Maternal blood pressure 4 Maternal uterine contractions
Fetal physical activity
A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential? 1 Fundal height 2 Obstetric history 3 Time of the last meal 4 Family history of bleeding disorders
Fundal height
The nurse is interviewing a 41-year-old woman who is being seen in the infertility clinic for her first visit. She and her husband have been married for 3 years and have not used any form of contraception during this time. Neither the woman nor her husband has children from previous relationships. She asks the nurse what test or treatment will be done first. The nurse informs her that she and her husband should first expect: 1 A laparoscopy 2 The start of fertility medication 3 A hysteroscopy 4 Semen analysis
Semen analysis
A nurse is caring for a postpartum client who had abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
Bleeding at the venipuncture site
A nurse is caring for a client who is receiving IV magnesium sulfate for preeclampsia. At 37 weeks' gestation she gives birth to an infant weighing 4 lb. What clinical finding in the newborn may indicate magnesium sulfate toxicity? 1 Pallor 2 Tremor 3 Hypotonia 4 Tachycardia
Hypotonia
A pregnant client with a history of heart disease asks how she can relieve her occasional heartburn, and the nurse teaches her self-care measures. What statement indicates to the nurse that the client understands the teaching? 1 "I should lie down an hour after I eat." 2 "I shouldn't drink more than a quart a day." 3 "I won't take antacids that contain sodium." 4 "I plan to eat three evenly spaced meals throughout the day."
"I won't take antacids that contain sodium."
The nurse is reviewing the breast self-examination procedure with a client. What comment by the client should the nurse should consider significant? 1 "My breasts feel larger when I'm having a period." 2 "My breasts feel lumpy right before my period starts." 3 "My left breast has always been a little bigger than my right one." 4 "My right breast feels thicker and seems bigger than the left one."
"My right breast feels thicker and seems bigger than the left one."
A client who is admitted to the high-risk unit with severe preeclampsia anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? 1 "There is no way of telling at this time what the outcome will be." 2 "Your baby probably will be all right. It's protected by the amniotic fluid." 3 "If you follow your health care provider's instructions, everything will progress normally." 4 "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat."
"We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat."
A nurse is teaching a family planning class about ovulation and conception. The nurse should instruct the class that the ovum is thought to be viable for what period of time after ovulation? 1 1 to 6 hours 2 12 to 18 hours 3 24 to 36 hours 4 48 to 72 hours
24 to 36 hours
What should a nurse include in the teaching plan for a couple seeking information about family planning? 1 A condom must be held in place by the rim when the penis is withdrawn from the vagina. 2 Diaphragms are effective even when the partners choose not to use a spermicidal cream. 3 When the coitus interruptus method is used, sperm cannot reach the ovum if the man withdraws before ejaculation. 4 When periodic abstinence is used, the woman should have intercourse on days when she has an increase in temperature.
A condom must be held in place by the rim when the penis is withdrawn from the vagina.
A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What side effects indicate that the serum magnesium level may be excessive? Select all that apply. 1 Absence of the knee-jerk reflex 2 Urine output of 100 mL/hr 3 Blood pressure of 140/90 mm Hg 4 Apical pulse of 80 beats/min 5 Respiratory rate of 11 breaths/min
Absense of the knee jerk reflex and respiratory rate of 11 breaths per min
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take? 1 Discontinuing the test because the pattern is within the expected range 2 Encouraging the client to drink more fluids to decrease the fetal heart rate 3 Notifying the primary health care provider and preparing for an emergency birth 4 Recording this nonreassuring pattern and continuing the test for further evaluation
Discontinuing the test because the pattern is within the expected range
A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What clinical finding indicates an impending seizure? 1 Persistent headache with blurred vision 2 Epigastric pain with nausea and vomiting 3 Spots and flashes of light before the eyes 4 Rolling of the eyes to one side with a fixed stare
Rolling of the eyes to one side with a fixed stare.
A client at 16 weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her that he has genital herpes. What should the nurse include when teaching the client about sexual activity? 1 Condoms must be used when the couple is having intercourse. 2 Sexual abstinence should be practiced during the last 6 weeks. 3 It will be necessary to refrain from sexual contact during pregnancy. 4 Meticulous cleaning of the vaginal area after intercourse is essential.
Sexual abstinence should be practiced during the last 6 weeks
A nurse provides crisis intervention for a client who recently left her husband because of physical abuse. Which client behaviors indicate to the nurse that the therapy has been successful? Select all that apply. 1 Is able to cry 2 Sleeps half the day 3 Utilizes healthier coping skills 4 Refuses a referral to support services 5 Describes the current situation realistically
Utilizes healthier coping skills and described the current situation realistically
A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of five pounds since the previous checkup one week ago. During the assessment, symptoms suggestive of preeclampsia were obtained. Select all that apply. 1 Headache 2 Double vision 3 Brisk reflexes 4 Epigastric pain 5 Sluggish reflexes 6 Edema of +1 in lower extremities
Headache, double vision, brisk reflexes, epigastric pain
What should a nurse anticipate about the insulin requirements of a client with diabetes on her first postpartum day? 1 No change 2 A rapid increase 3 A slow, steady decrease 4 A sharp, sudden decrease
A sharp, sudden decrease
A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. What complication of severe preeclampsia requires diligent monitoring of the blood pressure? 1 Stroke 2 Hemorrhage 3 Precipitous labor 4 Disseminated intravascular coagulation
Stroke
What clinical finding does the nurse expect when assessing a client with abruptio placentae? 1 Flaccid uterus 2 Painless bleeding 3 Boardlike abdomen 4 Bright red bleeding
Boardlike abdomen
A client asks the nurse at the family planning clinic whether contraception is needed while she is breastfeeding. How should the nurse reply? 1 "As long as you aren't having periods, you won't need a contraceptive." 2 "It would be best to delay sexual relations until you have your first period." 3 "You should use contraceptives, because ovulation may occur without a period." 4 "Breastfeeding suppresses ovulation, so you don't need to worry about pregnancy."
"You should use contraceptives, because ovulation may occur without a period
A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. What does the nurse identify as the main reason that this medication is administered? 1 It acts as a diuretic. 2 It has a sedative effect. 3 It acts as an anticonvulsant. 4 It has an antihypertensive effect.
Anticonvulsant
A client at 38 weeks' gestation is admitted with the diagnosis of placenta previa. What is the priority nursing care at this time? 1 Withholding oral intake 2 Assessing for hemorrhage 3 Avoiding extraneous stimuli 4 Encouraging supervised ambulation
Assessing for hemorrhage
A client who is 21 weeks pregnant loses the baby because of an incompetent cervix. Once the client's physical needs have been assessed and met, what is the best way for the nurse to meet the client's psychological needs? 1 Encouraging the client to see and hold the baby while still possible 2 Taking photos and giving them to the client if she refuses to see the baby 3 Sending the baby to the morgue as soon as possible and discouraging any contact 4 Telling the client that the baby is decaying and it is probably for the best if the is client unsure about seeing the baby
Encouraging the client to see and hold the baby while still possible
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the care provider if the respiratory rate is slower than 20 breaths/min
Monitoring deep tendon reflexes, maintaining a dark/quiet environment, using a pump to regulate the medication, having calcium gluconate bedside
A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. What characteristic typical of placenta previa supports the nurse's conclusion? 1 Painful vaginal bleeding in the first trimester 2 Painful vaginal bleeding in the third trimester 3 Painless vaginal bleeding in the first trimester 4 Painless vaginal bleeding in the third trimester
Painless vaginal bleeding in the third trimester
A nurse is assessing a client with worsening preeclampsia. What is the most significant clinical manifestation of severe preeclampsia? 1 Polyuria 2 Vaginal spotting 3 Proteinuria of 3+ 4 Blood pressure of 130/80 mm Hg
Proteinuria of 3+
How should a nurse screen the newborn of a diabetic mother for hypoglycemia? 1 Testing for glucose tolerance 2 Drawing blood for a serum glucose determination 3 Arranging for a fasting blood glucose determination 4 Testing heel blood with the use of a glucose-oxidase strip
Testing heel blood with the use of a glucose-oxidase strip
Placenta previa is diagnosed after a client at 24 weeks' gestation experiences painless vaginal bleeding. The client is concerned that she has done something to cause the bleeding. How should the nurse respond? 1 "It's not your fault; these things happen." 2 "Don't worry; it's just a sign that labor is beginning." 3 "Your uterus may be weak—that's what causes the vaginal bleeding." 4 "You have a low-lying placenta that separates when the cervix dilates."
"You have a low-lying placenta that separates when the cervix dilates."
A couple interested in family planning ask the nurse about the cervical mucus method of family planning. The nurse explains that with this method the couple must avoid intercourse when and a few days after the cervical mucus is: 1 Clear and thick 2 Yellow and thin 3 Cloudy and viscid 4 Clear and stretchable
Clear and stretchable
A woman who has experienced spousal abuse is working with the nurse to develop a plan for safety. What should the nurse instruct the client to do? 1 Enlist the help of a family member. 2 Limit verbal interactions with her husband. 3 Determine a safe place to go before it becomes necessary. 4 Keep the domestic violence hotline phone number in her wallet.
Determine a safe place to go before it becomes necessary
What should the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? 1 Bedrest with sedation 2 Trendelenburg position and hydration 3 Preparation for emergency cesarean birth 4 External fetal monitoring and oxygenation
External fetal monitoring and oxygenation
A pregnant client asks the clinic nurse how smoking will affect her baby. What information about cigarette smoking will influence the nurse's response? 1 It relieves maternal tension, and the fetus responds accordingly to the reduction in stress. 2 The resulting vasoconstriction affects both fetal and maternal blood vessels. 3 Substances contained in smoke diffuse through the placenta and compromise the fetus's well-being. 4 Effects are limited because fetal circulation and maternal circulation are separated by the placental barrier.
The resulting vasoconstriction affects both fetal and maternal blood vessels.
A left modified radical mastectomy is performed on a client with breast cancer. What is the most important measure to be included in the care plan for the first postoperative day? 1 Having someone from Reach to Recovery visit the client 2 Emptying the portable wound drainage system after each shift 3 Keeping the left arm and shoulder immobile until drainage ceases 4 Placing the client in the semi-Fowler position with the left arm and hand elevated
Placing the client in the semi-Fowler position with the left arm and hand elevated
A primigravida in whom placenta previa has already been diagnosed is admitted with bright-red vaginal bleeding at 34 weeks' gestation. What is the nurse's initial intervention? 1 Ambulating the client to facilitate labor contractions 2 Inserting an internal scalp electrode to assess fetal heart tones 3 Performing a vaginal examination to determine progression of labor 4 Positioning the client in the side-lying position to ease pressure on the cervix
Positioning the client in the side-lying position to ease pressure on the cervix
A nurse is caring for a client who was admitted with the diagnosis of severe preeclampsia and is now receiving an intravenous infusion of magnesium sulfate. What is the classification of this medication? 1 Diuretic 2 Oxytocic 3 Antihypertensive agent 4 Central nervous system depressant
CNS depressant
A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. How should the nurse respond? 1 "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." 2 "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." 3 "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." 4 "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
A client who has undergone a cesarean birth because of the presence of active genital herpes is transferred to the postpartum unit. What type of isolation precautions does the nurse plan to institute? 1 Enteric 2 Droplet 3 Contact 4 Airborne
Contact
While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs? 1 Seizure activity is imminent. 2 Pulmonary edema has developed. 3 Bronchial constriction was precipitated by the stress of pregnancy. 4 Impaired diaphragmatic function was caused by the enlarged uterus.
Pulmonary edema has developed
A client who is at risk for seizures as a result of severe preeclampsia is receiving an IV infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. 1 Proteinuria 2 Epigastric pain 3 Respirations of 10/min 4 Loss of patellar reflexes 5 Urine output of 40 mL/hr
Respirations of 10/min and loss of patellar reflexes
A client seeking family planning information asks the nurse during which phase of the menstrual cycle an intrauterine device (IUD) should be inserted. Before responding the nurse recalls that the insertion usually is done: 1 Between the first and fourth days of the cycle 2 Between the fifth and 11th days 3 Between the 14th and 16th days 4 Between the 25th and 28th days
Between the first and fourth days of the cycle
A client who is visiting the family planning clinic is prescribed an oral contraceptive. As part of teaching, the nurse plans to inform the client of the possibility of: 1 Cervicitis 2 Ovarian cysts 3 Fibrocystic disease 4 Breakthrough bleeding
Breakthrough bleeding
A 24-year-old woman wants to use her basal body temperature (BBT) in natural family planning but is unsure when to take her temperature. The nurse informs her that an accurate BBT is best taken: 1 Each night right before bed 2 On the first day of her next menstrual cycle 3 Each morning prior to getting out of bed or increasing her activity 4 At bedtime beginning on day 14 of her menstrual cycle and continuing until her next period
Each morning prior to getting out of bed or increasing her activity
A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. What hemodynamic change of pregnancy may affect the client at this time? 1 Decreased red blood cell count 2 Gradually increasing size of the uterus 3 Heart rate acceleration in the last half of pregnancy 4 Increase in cardiac output during the third trimester
Heart rate acceleration in the last half of pregnancy
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? 1 Insulin needs will increase during the second trimester. 2 Insulin needs will decrease during the second trimester. 3 Insulin needs will not change during the second trimester. 4 Insulin will be switched to an oral antidiabetic medication during the second trimester.
Insulin needs will increase during the second trimester.
A nurse in the women's health clinic is counseling clients about family planning. What should the nurse consider when discussing the effects of a high concentration of estrogen in the blood? 1 It causes ovulation. 2 Lactation is stimulated. 3 It prompts secretion of oxytocin. 4 It inhibits secretion of follicle-stimulating hormone (FSH).
It inhibits secretion of follicle-stimulating hormone (FSH).
A client with severe preeclampsia is receiving magnesium sulfate therapy. What is the priority nursing assessment as the nurse monitors this client's response to therapy? 1 Urine output 2 Respiratory rate 3 Deep tendon reflexes 4 Level of consciousness
Respiratory rate
A client is admitted with a marginal placenta previa. What should the nurse have available? 1 One unit of freeze-dried plasma 2 Vitamin K for intramuscular injection 3 Two units of typed and screened blood 4 Heparin sodium for intravenous injection
Two units of typed and screened blood
While a client is being given intravenous magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. The nurse explains to the client that this is done because it: 1 Reveals her level of consciousness 2 Reveals the mobility of the extremities 3 Reveals the response to painful stimuli 4 Identifies the potential for respiratory depression
Identifies the potential for respiratory depression
A nurse is monitoring a client with severe preeclampsia who is receiving an infusion of magnesium sulfate. Assessment reveals a pulse rate of 55 beats/min, respiratory rate of 10 beats/min, and a flushed face. What are the next nursing actions? 1 Continuing the infusion and notifying the health care provider 2 Stopping the infusion and starting an infusion of dextrose and water 3 Continuing the infusion and documenting the findings in the clinical record 4 Decreasing the rate of the infusion and obtaining blood for a magnesium level
Stopping the infusion and starting an infusion of dextrose and water
A nurse is teaching a class of premenopausal women how to perform breast self-examination correctly. What is the best time of the month for breast self-examination? 1 When ovulation occurs 2 The first day of every month 3 The day that the menses begins 4 About a week after menses ends
About a week after menses ends
A health care provider plans to perform a vaginal examination of a client with a partial placenta previa. What should the nurse have available when this examination is performed? 1 1 unit of freeze-dried plasma 2 Vitamin K and a syringe for injection 3 Heparin sodium for intravenous infusion 4 2 units of typed and crossmatched blood
2 units of typed and crossmatched blood
A nurse in a family planning clinic determines that a client understands the discussion about using a cervical cap with a spermicide when the client states that after intercourse, a cervical cap must be left in place for at least: 1 6 hours 2 5 hours 3 3 hours 4 2 hours
6 hours
A nurse is presenting a community education program about osteoporosis at a women's health conference. What factor should the nurse explain has contributed to the increased incidence of fractures associated with osteoporosis in the United States? 1 Dietary use of fat-free milk 2 Aging of the American population 3 Increased number of hysterectomies 4 Immobility associated with early retirement
Aging of the American population
A 17-year-old client tells the nurse that her sister had an ectopic pregnancy about 3 months ago and had to have her fallopian tube removed. The nurse determines that this young woman needs additional information when she states: 1 "Pelvic infections can cause this to happen." 2 "This kind of thing could happen to my sister again." 3 "I guess I'll have to wait a while to become an aunt." 4 "My sister is lucky, because she won't have a period again."
"My sister is lucky, because she won't have a period again."
A nurse on the high-risk unit is caring for a client with severe preeclampsia. What intervention is most effective in preventing a seizure? 1 Providing a plastic airway 2 Controlling external stimuli 3 Having emergency equipment available 4 Keeping calcium gluconate at the bedside
Controlling external stimuli
A couple interested in delaying the start of a family discuss the various methods of family planning. Together they decide to use the basal body temperature method. The nurse explains that the fertile period surrounding ovulation lasts from: 1 12 hours before to 24 hours after ovulation 2 72 hours before to 24 hours after ovulation 3 72 to 80 hours before to 72 hours after ovulation 4 24 to 48 hours before to 48 hours after ovulation
72 hours before to 24 hours after ovulation
A nurse is caring for a client who is being given intravenous magnesium sulfate to treat preeclampsia. Which adverse side effect alerts the nurse to notify the health care provider? 1 Respiratory rate of 18 breaths/min 2 2+ patellar reflex response 3 Magnesium blood level of 5 mEq/L 4 Urine output of less than 100 mL in 4 hours
Urine output of less than 100 mL in 4 hours
A client who had a severe abruptio placentae asks the nurse why there was so much bleeding. What should the nurse consider as the cause of the heavy bleeding before responding in language that the client will understand? 1 Polycythemia 2 Thrombocytopenia 3 Hyperglobulinemia 4 Hypofibrinogenemia
Hypofibrinogenemia
A client at 30 weeks' gestation is admitted to the hospital with a diagnosis of low-lying placenta previa with slight vaginal bleeding. The client is stabilized, and bleeding ceases. What is the nurse's primary focus when providing discharge teaching about care at home for this client? 1 Stay on strict bedrest and use a bedpan. 2 Maintain a calm and quiet environment. 3 Check fetal status with a stethoscope daily. 4 Avoid situations that may stimulate the cervix or uterus.
Avoid situations that may stimulate the cervix or uterus
A client in the prenatal clinic is diagnosed with preeclampsia. What clinical findings support this diagnosis? 1 Increased blood pressure of 150/100 mm Hg 2 Increased blood pressure that is accompanied by a headache 3 Blood pressure above the baseline that fluctuates with each reading 4 Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria
Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria
What nursing intervention should be included in the care of a client with placenta previa? 1 Vital signs at least once per shift 2 Tap water enema before the birth 3 Documentation of the amount of bleeding 4 Limited ambulation until the bleeding stops
Documentation of the amount of bleeding
A nurse is reviewing the obstetric history of a client who had an abruptio placentae. What prenatal condition does the nurse expect the client to have had? 1 Cardiac disease 2 Hyperthyroidism 3 Gestational hypertension 4 Cephalopelvic disproportion
Gestational hypertension
A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Visual disturbances
Headache, abdominal pain, visual disturbances
A nurse is performing a physical assessment of a pregnant woman. What factor in the client's history increases the risk for abruptio placentae? 1 Hydramnios 2 Hypertension 3 Cardiac disease 4 Diabetes mellitus
Hypertension
A nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. For what complication associated with this problem should the nurse monitor this client? 1 Brain attack 2 Pulmonary edema 3 Impending seizures 4 Hypovolemic shock
Hypovolemic shock
A woman in the family planning clinic has decided to use the diaphragm for contraception. What should the nurse teach her about using a diaphragm? 1 Completely cover the outside of the diaphragm with spermicidal jelly or cream. 2 Douche within 1 hour of intercourse to enhance the effectiveness of the diaphragm. 3 Correct placement of the diaphragm leaves an inch between the diaphragm and the vaginal wall. 4 Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm.
Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm.
A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety? 1 Institute seizure precautions. 2 Decrease environmental stimuli. 3 Administer the prescribed sedatives. 4 Strictly monitor her intake and output.
Institute seizure precautions
A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene? 1 Hyperactive sensorium 2 Increase in respiratory rate 3 Lack of the knee-jerk reflex 4 Development of a cardiac dysrhythmia
Lack of knee jerk reflex
A nurse is teaching a prenatal class about smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? 1 Low birthweight 2 Facial abnormalities 3 Chronic lung problems 4 Hyperglycemic reactions
Low birthweight
Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? 1 Receives long-term steroid therapy 2 Has a history of hypoparathyroidism 3 Engages in strenuous physical activity 4 Consumes high doses of the hormone estrogen
Receives long term steroid therapy
A client with a diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. What precaution should the nurse initiate? 1 Padding the side rails on the bed 2 Placing the call button next to the client 3 Having oxygen and a facemask available 4 Assigning a nursing assistant to stay with the client
Placing the side rails on the bed
What is the priority nursing intervention for a client with severe preeclampsia? 1 Isolating her in a dark room 2 Maintaining her in a supine position 3 Encouraging her to drink clear fluids 4 Protecting her against extraneous stimuli
Protecting her against extraneous stimuli
The public health nurse presents a program on breast self-examination. After a return demonstration the nurse concludes that she needs to review certain aspects of the teaching program. Which behavior by one of the students supports this conclusion? 1 Palpating each breast while in the sitting position 2 Checking her breasts for any deviation from what is expected 3 Palpating each breast with the palmar surface of her extended fingers 4 Checking her breasts for symmetry while holding her arms above her head
Palpating each breast while in the sitting position
