Quiz Qs: Exam 3

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? Infection Hemorrhage Chronic hypertension Disseminated intravascular coagulation

Hemorrhage

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. Use of diaphragm History of Chlamydia Use of fertility medications Use of an intrauterine device History of pelvic inflammatory disease (PID)

History of Chlamydia Use of fertility medications Use of an intrauterine device History of pelvic inflammatory disease (PID)

Which is the priority nursing action for the client with an ectopic pregnancy? Assessing urine for proteinuria Checking the electrolyte values Monitoring for signs of infection Monitoring the pulse and blood pressure

Monitoring the pulse and blood pressure

The senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The co-assigned registered nurse asks the student to describe the actions and effects of this medication. Which statement, if made by the student, indicates the need for further teaching? "It decreases the frequency and duration of uterine contractions." "It increases acetylcholine, blocking neuromuscular transmission." "It decreases the central nervous system activity, acting as an anticonvulsant." "It produces flushing and sweating due to decreased peripheral blood pressure."

"It increases acetylcholine, blocking neuromuscular transmission." Magnesium sulfate decreases (not increases) acetylcholine, blocking neuromuscular transmission.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? "What can I do for you?" "Now you have an angel in heaven." "Don't worry. There is nothing you could have done to prevent this from happening." "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

"What can I do for you?"

The multigravida mother with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" Which of the following would be the nurse's first action? A. Inspect the perineum. B. Time the contractions. C. Auscultate the fetal heart rate. D. Contact the birth attendant.

A

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? Assess for signs and symptoms of labor. Assess the client's temperature every 2 hours. Schedule a daily ultrasound to assess fetal movement. Schedule a nonstress test every 4 hours to assess fetal well-being.

Assess for signs and symptoms of labor. As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action would the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? Allow family members to name the infant. Encourage the client to talk about the dead fetus. Allow the client and the spouse to hold the infant. Assess the client's and the spouse's perception of the event.

Assess the client's and the spouse's perception of the event.

A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? A. Placenta previa B. Abruptio placentae C. Ectopic pregnancy D. Spontaneous abortion

B

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse would prepare the client for which anticipated prescription? Delivery of the fetus Strict monitoring of intake and output Complete bed rest for the remainder of the pregnancy The need for weekly monitoring of coagulation studies until the time of delivery

Delivery of the fetus Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse would monitor for which adverse effects of this medication? Select all that apply. Flushing Hypertension Increased urine output Depressed respirations Extreme muscle weakness Hyperactive deep tendon reflexes

Depressed respirations Extreme muscle weakness Flushing

The nurse is assessing a client who is at 28 weeks' gestation and is complaining of pelvic pain. The client is diagnosed with symphysis pubis dysfunction. The nurse explains that this condition occurs in response to hormones inducing joint instability and widening in the pelvis to accommodate childbirth. The nurse would explain to the client that which hormones increase joint laxity? Select all that apply. Relaxin Cortisol Aldosterone Testosterone Progesterone

Progesterone Relaxin

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? Provide pain relief measures. Prepare the client for an amniotomy. Promote ambulation every 30 minutes. Monitor the oxytocin infusion closely.

Provide pain relief measures.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? Provide pain relief measures. Prepare the client for an amniotomy. Promote ambulation every 30 minutes. Monitor the oxytocin infusion closely.

Provide pain relief measures. Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.

The nurse is caring for a pt and the pt is prescribed terbutaline. After assessment the nurse tells the PCP that terbutaline is contraindicated in this pt based on what finding? A. BP 80/60 B. Short episode of hyperglycemia C. Irregular episode of dysrhythmias D. HR less than 120

A If the HR was greater than 130 than the tx would be stopped

For which condition is the pt at risk in early pregnancy d/t poorly controlled hyperG? A. Miscarriage B. Hydramnios C. Pre-E D. Ketoacidosis

A (hydramnios occurs in the 3rd tri)

A client with severe pre-e has been recieving mag for 8 hrs. The nurse assesses the client and documents the following: Temp 37.1C, pulse 96, RR 24, BP 155/112, 3+ DTR and no ankle clonus. The nurse calls the PCP and anticipates a prescription for which med? A. Hydralazine B. Mag sulfate bolus C. Diazepam D. Calcium gluconate

A Hydralazine is an anti-HTN med commonly used to treat HTN in severe pre-E. An additional bolus of mag sulfate may be prescribed for increasing s/s of CNS irritability r/t severe pre-E

A pregnant client ROMs and they have a prolapsed cord suspected. Which is the priority nursing intervention? A. place pt in knee to chest B. Cover the cord with a sterile towel saturated with warm NS C. Prep for c/s D. Start O2 via facemask

A (can do modified sims or trendelenberg too) If the cord protrudes from vagina you can cover it with sterile towel soaked in NS

Why would BP be frequently assessed with hydralazine?

A precipitous drop can lead to shock and placental abruption

A client at 39w with a hx of pre-E is admitted to L and D. She suddenly experiences increased contraction frequency of every 1-2 min; dark red vaginal bleeding and a tense, painful abd. The nurse would susect the onset of which client condition? A. Eclamptic seizure B. Uterine rupture C. Placenta previa D. Abruptio placentae

D

A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first? A. Pad the side rails. B. Place a pillow under the left buttock. C. Insert a padded tongue blade into the mouth. D. Maintain a patent airway.

D

At 26 weeks the nurse is assessing a pt for PTL. Which finding indicated PTL? A. Estriol is not found in maternal saliva B. Irregular, mild uterine contractions occur every 12-15 min C. fFN is present in vaginal secretions D. Cervix is effacing and dilated to 2cm

D

The nurse is caring for a pregnant client with CHTN. Which additional complication is most likely to be seen in this client? A. Eclampsia B. Pre-E C. GDM D. Superimposed pre-E

D

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Painless, bright red vaginal bleeding Increased uterine resting tone on fetal monitoring

Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Increased uterine resting tone on fetal monitoring

Which factors may prohibit the pt from having a vaginal birth? SA A. Unstable coronary artery disease B. Previous c/s C. Placenta previa D. Initial BP of 132/87 E. Hx of three spontaneous abortions

A, B, C

In assessing the pregnant client, the nurse is aware that which metabolic changes are associated with pregnancy? SA A. Maternal production of insulin increases during the 1st tri B. Fasting BG levels decrease during the 1st tri C. Client's tolerance to glucose increases in the 2nd tri D. There is enough glucose for the fetus in the 2nd tri E. Maternal insulin requirements increase during the 1st tri

A, B, D

For which condition would the nurse be alert after administering terbutaline to a pregnant client with DM? A. Dyspnea B. Infection C. Ketoacidosis D. Hypoglycemia

C Terbutaline can lead to hyperglycemia and cause ketoacidosis

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse would take which first action? Administer oxygen by face mask. Clear and maintain an open airway. Administer magnesium sulfate intravenously. Assess the blood pressure and fetal heart rate.

Clear and maintain an open airway.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? The client is a 35-year-old primigravida. The client has a history of cardiac disease. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). The client is a 20-year-old primigravida of average weight and height.

The client has a history of cardiac disease.

The nurse is aware of which factor regarding the use of tocolytic therapy to supress uterine activity? A. The drugs can be given efficaciously up to the designated beginning of term at 37 w B. There are no important maternal contrainidications C. Its most important function is to afford the opportunity to administer antenatal glucocorticoids D. If the client develops pulmonary edema while on tocolytics, IV fluids would be given

C Tocolytics shouldn't be used past 34 w

Which factors would lead to an increased likelihood of uterine rupture? SA A. Preterm singleton B. G3P3 with all vaginal births C. Short interval between pregnancies D. TOLAC after VBAC E. Had a primary c/s with a classical incision

C, D, E

Which conditions would the nurse remain alert for in a pregnant client with pre-E? SA A. Seizures B. Scotoma C. Renal disease D. Cerebral edema E. Chronic HTN

A, B, D

Which are common causes of indicated PTL? SA A. Herpes infections B. Multifetal gestation C. Gestational DM D. CHTN E. 2nd tri bleeding

A, C, D

The nurse is caring for a PP client recieving IV mag. Which other meds would the nurse check for to ensure client safety? SA A. Narcotics B. Diuretics C. Analgesics D. CCBs E. CNS depressants

A, D, E

The nurse is assessing a client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings would the nurse expect to note if abruptio placentae is present? Select all that apply. Soft uterus Abdominal pain Nontender uterus Firm uterus by palpation Painless vaginal bleeding

Abdominal pain Firm uterus by palpation

The nurse is caring for a pregnant client with CHTN. Which additional complication is most likely to be seen in this client? A. Eclampsia B. Pre-E C. Gestational DM D. Superimposed preE

D

What is the priority nursing action when a pregnant client with severe GHTN is admited to the health care facility? A. prepare the client for a c/s B. Administer IV and oral fluids C. Provide diversionary activities during bed rest D. Administer prescribed mag sulfate

D

A pregnant client has gotten terbutaline. The nurse finds that the pt has a HR of 140 and chest pain. What is the best nursing action? A. Administer propanalol B. Administer IV fluids C. Administer 1g calcium gluconate D. Notify the PCP

D While propanaol reverses the cardiovascular adverse effects of Terbutaline it needs to be prescribed.

The nurse is preparing to perform a fetal fibronectin test for a pregnant client. Which intervention would the nurse perform to collect the sample for the test? A. Take a blood sample from the forearm B. Take a sample of the client's amniotic fluid C. Ask the client to provide a urine sample D. Collect the vaginal secretions using a swab

D.

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? Checking for edema Monitoring daily weight Monitoring the apical pulse Monitoring the temperature

Monitoring the 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.

The labor room nurse assists with the administration of a lumbar epidural block. How would the nurse check for the major side effect associated with this type of regional anesthesia? Assessing the client's reflexes Taking the client's temperature Taking the client's apical pulse Monitoring the client's blood pressure

Monitoring the client's blood pressure A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 5 minutes during the first 15 minutes and then at 30 minutes and 1 hour. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

Which initial nursing action is appropriate when caring for a client who has had an eclamptic seizure? A. Start an IV B. Administer O2 C. Monitor VS D. Insert an indwelling cath

B Nonrebreather at 10L/min

Which is the priority nursing action after administering mag to a client? A. Assess the client's weight B. Assess the serum mag level C. Restrict fluid to 250ml/hr D. Eval the fetal movement counts hourly

B Mag sulfate does not affect the FHR, so assessing fetal movements is not a priority.

The nurse is caring for a newborn after a vacuum delivery. Which changes would the nurse monitor in the newborn? SA A. Inability to pass urine B. Yellow discoloration of skin C. Listlessness D. Poor sucking patterns E. Difficulty breathing

B, C, D, E is not necessarily caused by vacuum assisted delivery

After the spontaneous rupture of the membranes of a client in labor, the fetal heart rate drops to 85 beats/minute. Which would be the nurse's priority action? Reposition the client to knee-chest. Assess the vagina and cervix with a gloved hand. Notify the primary health care provider of the need for an amnioinfusion. Document the description of the fetal bradycardia in the nursing notes.

Assess the vagina and cervix with a gloved hand.

Which system is a nursing priority after evaluating the information from the electronic health record for a client admitted with newly diagnosed pre-E? A. Liver B. Renal C. Neurologic D. Hematologic

B

Which tocolytic agent is contraindicated in a pt with a hx of migranes? A. Nifedipine B. Terbutaline C. Mag

B Nifedipine is contraindicated in pts with HTN

Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient's lab results correlate with HELLP Syndrome? A. Hemoglobin 12 g/dL B. Platelets 90,000 μL C. ALT 100 IU/L D. AST 90 IU/L E. Glucose 350 mg/dL F. Abnormal RBC peripheral smear

B, C, D, F

The nurse is teaching a group of pregnant clients about the early s/s of PTL. Which s/s should be included? SA A. Upper abd pain B. Increased vaginal discharge C. Vaginal bleeding D. Decreased urinary frequency E. Painful uterine contractions

B, C, E

When assessing a pregnant client, the nurse is aware of which complications associated with polyhydramnios? SA A. Ketoacidosis B. Placental abruption C. Uterine dysfunction D. Gestational DM E. PPH

B, C, E GDM can cause polyhydramnios but it is not a complication of it

A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: A. Weekly fetal movement counts are made by the mother. B. Contraction stress testing is performed weekly. C. Induction of labor begins at 34 weeks' gestation. D. Nonstress testing is performed weekly until 32 weeks' gestation.

D