ABNORMAL OB

33. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: A. Uterine inversion B. Uterine atony C. Uterine involution D. Uterine discomfort

100. Answer: (B) Uterine atony. Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

49. Which of the following refers to the single cell that reproduces itself after conception? A. Chromosome B. Blastocyst C. Zygote D. Trophoblast

Answer (C) Zygote. The zygote is the single cell that reproduces itself after conception. The chromosome is the material that makes up the cell and is gained from each parent. Blastocyst and trophoblast are later terms for the embryo after zygote.

29. Which of the following drugs is the antidote for magnesium toxicity? A. Calcium gluconate (Kalcinate) B. Hydralazine (Apresoline) C. Naloxone (Narcan) D. Rho (D) immune globulin (RhoGAM)

Answer: (A) Calcium gluconate (Kalcinate). Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity.

8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: A. Contractions every 1⁄2 minutes lasting 70-80 seconds. B. Maternal temperature 101.2 C. Early decelerations in the fetal heart rate. D. Fetal heart rate baseline 140-160 bpm.

Answer: (A) Contractions every 1 minutes lasting 70-80 seconds. Contractions every 1⁄2 minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.

26. Emily has gestational diabetes and it is usually managed by which of the following therapy? A. Diet B. Long-acting insulin C. Oral hypoglycemic D. Oral hypoglycemic drug and insulin

Answer: (A) Diet. Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin usually isn't needed for blood glucose control in the client with gestational diabetes.

5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? A. Excessive fetal activity. B. Larger than normal uterus for gestational age. C. Vaginal bleeding D. Elevated levels of human chorionic gonadotropin.

Answer: (A) Excessive fetal activity. The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted.

1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? A. Inevitable B. Incomplete C. Threatened D. Septic

Answer: (A) Inevitable. An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.

11. The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)? A. Intrauterine fetal death. B. Placenta accreta. C. Dysfunctional labor. D. Premature rupture of the membranes.

Answer: (A) Intrauterine fetal death. Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC.

40. A postpartum client has a temperature of 101.4oF, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next? A. Lochia B. Breasts C. Incision D. Urine

Answer: (A) Lochia. The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. All the client's data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101oF, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected. The client data do not include dysuria, frequency, or urgency, symptoms of urinary tract infections, which would necessitate assessing the client's urine.

14. A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by: A. Menorrhagia B. Metrorrhagia C. Dyspareunia D. Amenorrhea

Answer: (A) Menorrhagia. Menorrhagia is an excessive menstrual period.

45. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing? A. Obtaining an order to begin IV oxytocin infusion B. Administering a light sedative to allow the patient to rest for several hour C. Preparing for a cesarean section for failure to progress D. Increasing the encouragement to the patient when pushing begins

Answer: (A) Obtaining an order to begin IV oxytocin infusion. The client's labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. Administering light sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions.

17. Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected? A. Placenta previa B. Abruptio placentae C. Premature labor D. Sexually transmitted disease

Answer: (A) Placenta previa. Placenta previa with painless vaginal bleeding.

6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: A. Urinary output 90 cc in 2 hours. B. Absent patellar reflexes. C. Rapid respiratory rate above 40/min. D. Rapid rise in blood pressure.

Answer: (B) Absent patellar reflexes. Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.

44. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following? A. Braxton-Hicks sign B. Chadwick's sign C. Goodell's sign D. McDonald's sign

Answer: (B) Chadwick's sign. Chadwick's sign refers to the purple-blue tinge of the cervix. Braxton Hicks contractions are painless contractions beginning around the 4th month. Goodell's sign indicates softening of the cervix. Flexibility of the uterus against the cervix is known as McDonald's sign.

47. The nurse understands that the fetal head is in which of the following positions with a face presentation? A. Completely flexed B. Completely extended C. Partially extended D. Partially flexed

Answer: (B) Completely Extended. With a face presentation, the head is completely extended. With a vertex presentation, the head is completely or partially flexed. With a brow (forehead) presentation, the head would be partially extended.

13. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is: A. Anemia B. Decreased urine output C. Hyperreflexia D. Increased respiratory rate

Answer: (B) Decreased urine output. Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels.

2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion? A. Age 36 years B. History of syphilis C. History of genital herpes D. History of diabetes mellitus

Answer: (B) History of syphilis. Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.

35. A client 12 weeks' pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation. The nurse would document these findings as which of the following? A. Threatened abortion B. Imminent abortion C. Complete abortion D. Missed abortion

Answer: (B) Imminent abortion. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion. In a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. The symptoms may subside or progress to abortion. In a complete abortion all the products of conception are expelled. A missed abortion is early fetal intrauterine death without expulsion of the products of conception.

4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require: A. Decreased caloric intake B. Increased caloric intake C. Decreased Insulin D. Increase Insulin

Answer: (B) Increased caloric intake. Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin and is referred to as the diabetogenic effect of pregnancy.

22. Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A. Applying cold to limit edema during the first 12 to 24 hours. B. Instructing the client to use two or more peripads to cushion the area. C. Instructing the client on the use of sitz baths if ordered. D. Instructing the client about the importance of perineal (kegel) exercises.

Answer: (B) Instructing the client to use two or more peri pads to cushion the area. Using two or more peri pads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.

36. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy? A. Risk for infection B. Pain C. Knowledge Deficit D. Anticipatory Grieving

Answer: (B) Pain. For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority. Although the potential for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving, but this is not the priority at this time.

31. Rh isoimmunization in a pregnant client develops during which of the following conditions? A. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. B. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. C. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. D. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies.

Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells.

42. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client's plan of care? A. Daily weights B. Seizure precautions C. Right lateral positioning D. Stress reduction

Answer: (B) Seizure precautions. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Because of edema, daily weight is important but not the priority. Pre-eclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.

21. Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this procedure, the nurse Hazel checks the fetal heart tones for which the following reasons? A. To determine fetal well-being. B. To assess for prolapsed cord C. To assess fetal position D. To prepare for an imminent delivery.

Answer: (B) To assess for prolapsed cord. After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

43. A postpartum primipara asks the nurse, "When can we have sexual intercourse again?" Which of the following would be the nurse's best response? A. "Anytime you both want to." B. "As soon as choose a contraceptive method." C. "When the discharge has stopped and the incision is healed." D. "After your 6 weeks examination."

Answer: (C) "When the discharge has stopped and the incision is healed." Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Choice of a contraceptive method is important, but not the specific criteria for safe resumption of sexual activity. Culturally, the 6- weeks' examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.

12. A full term client is in labor. Nurse Betty is aware that the fetal heart rate would be: A. 80 to 100 beats/minute B. 100 to 120 beats/minute C. 120 to 160 beats/minute D. 160 to 180 beats/minute

Answer: (C) 120 to 160 beats/minute. A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system.

15. Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be: A. Oxygen saturation B. Iron binding capacity C. Blood typing D. Serum Calcium

Answer: (C) Blood typing. Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. Approximately 40% of a woman's cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding.

23. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do? A. Observing the pooling of straw-colored fluid. B. Checking vaginal discharge with nitrazine paper. C. Conducting a bedside ultrasound for an amniotic fluid index. D. Observing for flakes of vernix in the vaginal discharge.

Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes.

19. Marjorie has just given birth at 42 weeks' gestation. When the nurse assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body

Answer: (C) Desquamation of the epidermis. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate.

9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: A. Ventilator assistance B. CVP readings C. EKG tracings D. Continuous CPR

Answer: (C) EKG tracings. A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) through administration of calcium gluconate is an essential part of care.

41. Which of the following is the priority focus of nursing practice with the current early postpartum discharge? A. Promoting comfort and restoration of health B. Exploring the emotional status of the family C. Facilitating safe and effective self-and newborn care D. Teaching about the importance of family planning

Answer: (C) Facilitating safe and effective self-and newborn care. Because of early postpartum discharge and limited time for teaching, the nurse's priority is to facilitate the safe and effective care of the client and newborn. Although promoting comfort and restoration of health, exploring the family's emotional status, and teaching about family planning are important in postpartum/newborn nursing care, they are not the priority focus in the limited time presented by early post-partum discharge.

34. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client? A. Glucosuria B. Depression C. Hand/face edema D. Dietary intake

Answer: (C) Hand/face edema. After 20 weeks' gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is checked for glucose at each clinic visit, this is not the priority. Depression may cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is not, however, the priority consideration at this time. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time.

50. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says: A. I am happy to note that we can have sex occasionally when I have no bleeding. B. I am afraid I might have an operation when my due comes C. I will have to remain in bed until my due date comes D. I may go back to work since I stay only at the office.

Answer: (C) I will have to remain in bed until my due date comes. Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On the third trimester there is bleeding that is sudden, profuse and painless.

28. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures? A. Antihypertensive agents B. Diuretic agents C. I.V. fluids D. Acetaminophen (Tylenol) for pain

Answer: (C) I.V. fluids. A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually aren't necessary. Diuretic wouldn't be used unless fluid overload resulted.

24. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity? A. Cover his eyes while receiving oxygen. B. Keep her body temperature low. C. Monitor partial pressure of oxygen (Pao2) levels. D. Humidify the oxygen.

Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated.

3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority? A. Monitoring weight B. Assessing for edema C. Monitoring apical pulse D. Monitoring temperature

Answer: (C) Monitoring apical pulse. Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.

7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: A. Presenting part is 2 cm above the plane of the ischial spines. B. Biparietal diameter is at the level of the ischial spines. C. Presenting part in 2 cm below the plane of the ischial spines. D. Biparietal diameter is 2 cm above the ischial spines.

Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.

30. Dianne, 24 year-old is 27 weeks' pregnant arrives at her physician' s office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which of the following diagnoses is most likely? A. Asymptomatic bacteriuria B. Bacterial vaginosis C. Pyelonephritis D. Urinary tract infection (UTI)

Answer: (C) Pyelonephritis. The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn't cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms.

20. After reviewing the Myrna's maternal history of magnesium sulfate during labor, which condition would nurse Richard anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia

Answer: (C) Respiratory depression. Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. The serum blood sugar isn't affected by magnesium sulfate. The neonate would be floppy, not jittery.

52. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus: A. Need to be modified in any way by either partner B. Is permitted if penile penetration is not deep. C. Should be restricted because it may stimulate uterine activity. D. Is safe as long as she is in side-lying position.

Answer: (C) Should be restricted because it may stimulate uterine activity. Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous miscarriage occurred.

32. To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? A. Lateral position B. Squatting position C. Supine position D. Standing position

Answer: (C) Supine position. The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle.

46. Which of the following would be the nurse's most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa? A. "You will have to ask your physician when he returns." B. "You need a cesarean to prevent hemorrhage." C. "The placenta is covering most of your cervix." D. "The placenta is covering the opening of the uterus and blocking your baby."

Answer: (D) "The placenta is covering the opening of the uterus and blocking your baby." A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Telling the client to ask the physician is a poor response and would increase the patient's anxiety. Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur. With a complete previa, the placenta is covering all the cervix, not just most of it.

39. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician? A. A dark red discharge on a 2-day postpartum client B. A pink to brownish discharge on a client who is 5 days postpartum C. Almost colorless to creamy discharge on a client 2 weeks after delivery D. A bright red discharge 5 days after delivery

Answer: (D) A bright red discharge 5 days after delivery. Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells, erythrocyes, leukocytes and decidua. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

48. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas? A. Above the maternal umbilicus and to the right of midline B. In the lower-left maternal abdominal quadrant C. In the lower-right maternal abdominal quadrant D. Above the maternal umbilicus and to the left of midline

Answer: (D) Above the maternal umbilicus and to the left of midline. With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.

37. Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following should the nurse do first? A. Assess the vital signs B. Administer analgesia C. Ambulate her in the hall D. Assist her to urinate

Answer: (D) Assist her to urinate. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. Uterine assessment should not cause acute pain that requires administration of analgesia. Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.

51. Bettine Gonzales is hospitalized for the treatment of severe pre ecplampsia. Which of the following represents an unusual finding for this condition? A. generalized edema B. proteinuria 4+ C. blood pressure of 160/110 D. convulsions

Answer: (D) Convulsions. Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an obstetrical emergency.

38. The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4oF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first? A. Report the temperature to the physician B. Recheck the blood pressure with another cuff C. Assess the uterus for firmness and position D. Determine the amount of lochia

Answer: (D) Determine the amount of lochia. A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.

10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had: A. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. B. First and second caesareans were for cephalopelvic disproportion. C. First caesarean through a classic incision as a result of severe fetal distress. D. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.

Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery.

16. Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is: A. Metabolic alkalosis B. Respiratory acidosis C. Mastitis D. Physiologic anemia

Answer: (D) Physiologic anemia. Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production.

18. Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication? A. Anemia probably due to chronic fetal hypoxia B. Hyperthermia due to decreased glycogen stores C. Hyperglycemia due to decreased glycogen stores D. Polycythemia probably due to chronic fetal hypoxia

Answer: (D) Polycythemia probably due to chronic fetal hypoxia. The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.

27. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition? A. Hemorrhage B. Hypertension C. Hypomagnesemia D. Seizure

Answer: (D) Seizure. The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. Hypomagnesemia isn't a complication of preeclampsia. Antihypertensive drug other than magnesium are preferred for sustained hypertension. Magnesium doesn't help prevent hemorrhage in preeclamptic clients.

25. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa? A. Amniocentesis B. Digital or speculum examination C. External fetal monitoring D. Ultrasound

Answer: (D) Ultrasound. Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination shouldn't be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring won't detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta separation.