Exam Two Questions

A pregnant client at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse?

"It is best for you to visit a hospital immediately. They can use nitrazine paper to determine if it is amniotic fluid."

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best?

"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications."

A student nurse asks the instructor what percentage of clinically recognized pregnancies end in miscarriages during the first trimester. Which response from the nurse is the most accurate?

15% to 20%

A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?

Amniocentesis

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?

Dark red, "clumpy" vaginal discharge

A nurse is caring for a client who is postpartum and received methylergonovine. which of the following findings indicate that the medication was effective?

Fundus is firm to palpate

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?

Immediate surgery

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client?

Keep the suction equipment readily available.

The nurse understands the need to be aware of the potential of bleeding disorders in pregnant clients. Which disorder should she be aware of that occurs in the second trimester?

Placenta previa

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching?

Placenta previa is an abnormally implanted placenta that is too close to the cervix.

1. The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?

Reflexes

A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first?

Reposition the client to left side.

A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination & finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?

Threatened abortion

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? Respirations 16/min Headache for 30 min Urinary output 40 ml in 2 hr Fetal HR 156/min

Urinary output 40 ml in 2 hr

A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching? a. "Black cohosh should not be taken during pregnancy." b. "Black cohosh helps relieve headache pain." c. "Black cohosh increases the risk for bleeding." d. "Black cohosh is a stimulant."

a. "Black cohosh should not be taken during pregnancy."

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? a. Vastus lateralis b. Ventrogluteal c. Dorsogluteal d. Deltoid

a. Vastus lateralis

A nurse is caring for a client who just experienced a spontaneous abortion (miscarriage) in the first trimester. When asked by the client why this happened, which is the best response from the nurse?

abnormal fetal development

A nurse is caring for a client who is 28 weeks and received terbutaline. Which of the following findings should the nurse expect? a. Fetal HR 100/min b. Weakened uterine contractions c. Enhanced production of fetal lung surfactant d. Maternal blood glucose of 63 mg/dL

b. Weakened uterine contractions

A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use? a. Client is 42-years-old b. Client smokes cigarettes c. Client has pelvic relaxation d. Client has a 3-month-old infant

c. Client has pelvic relaxation

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? a. Postpartum infection b. Hypertension c. Postpartum hemorrhage d. Thromboembolic events

c. Postpartum hemorrhage

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? a. Slow the client's rate of breathing b. Increase the rate of infusion of the IV oxytocin c. Decrease the rate of infusion of the maintenance IV solution d. Discontinue the infusion of the IV oxytocin

d. Discontinue the infusion of the IV oxytocin

A nurse is caring for client who isn't in premature labor and is receiving terbutaline. The nurse should monitor the client for the following adverse effect that should be reported to the provider. a. HA b. Nervousness c. Tremors d. Dyspnea

d. Dyspnea

A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as:

hydatidiform mole

What would be the physiologic basis for a placenta previa?

low placental implantation

A pregnant client with preeclampsia with severe features has developed HELLP syndrome. In addition to the observations necessary for preeclampsia, what other nursing intervention is critical for this client?

observation for bleeding

A pregnant client with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose?

patellar reflex

During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition?

preeclampsia without severe features

A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?

prevent maternal D antibody formation.

The nurse is admitting a G3 P2 client at 38 weeks' gestation who arrived reporting painless bleeding from the vagina leading to the diagnosis of placenta previa. When questioned by the client as to what caused this, which most likely factor should the nurse point out in her answer?

previous cesarean birth

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mmHg & the fetal heart rate is 140/min. Which of the following is the priority nursing action? A. Elevate the client's legs. B. Monitor vital signs every 5 min. C. Notify the provider D. Place the client in a lateral position. Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava & improve the blood pressure.

D. Place the client in a lateral position. Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava & improve the blood pressure.

A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of LR with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include BP 146/95, pulse 80, RR 18. The nurse reviews the prescriptions from the provider. Which of the following prescriptions from the provider. Which of the following prescriptions requires clarification? A. Methylergonovine 0.2 mg IM now B. Insert an indwelling urinary catheter C. Administer O2 by nonrebreather mask at 5L/min D. Obtain lab study of prothrombin & partial thromboplastin time

A. Methylergonovine 0.2 mg IM now

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? A. A client who is experiencing fetal death at 32 weeks of gestation B. A client who is experiencing preterm labor at 26 weeks of gestation C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation D. A client who has a post-term pregnancy at 42 weeks of gestation

B. A client who is experiencing preterm labor at 26 weeks of gestation **Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the uterus in preterm labor.

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply). A. Prostaglandin E2: incorrect. Prostaglandin E2 is used to stimulate cervical ripening & hasten the onset of labor. B. Indomethacin C. Magnesium sulfate D. Methylergonovine: incorrect. Methylergonovine promotes uterine contractions to manage postpartum hemorrhage. E. Oxytocin: incorrect. Oxytocin is used to induce & augment labor.

B. Indomethacin C. Magnesium sulfate

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. which of the following statements should the nurse include in the teaching? a. "this medication promotes softening of the cervix." b. "this medication is used to treat preeclampsia." c. "It causes relaxation of the uterine muscles" d. "it is used to treat genital herpes simplex virus."

a. "this medication promotes softening of the cervix."

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? a. The client requires a rubella immunization following delivery. b. The client is not experiencing a rubella infection at this time c. The client is immune to the rubella virus d. The client requires a rubella vaccination at this time

a. The client requires a rubella immunization following delivery.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? a. Vomiting b. Tachycardia c. Respiratory depression d. Hypotension

d. Hypotension

A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition?

diabetes

A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP?

elevated lipoproteins