Test 3 Class Questions

- A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? o "I will need to remain on bed rest for 2 weeks." o "I will need to take a full course of antibiotic treatment." o "I will need to take tocolytic medication to halt the labor process." o "I will need to prepare myself and my family for the loss of this pregnancy."

"I will need to prepare myself and my family for the loss of this pregnancy."

- A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? o "My vision for the past 2 days has been really fuzzy" o "The swelling in my hands and ankles has gone down" o "I had heartburn yesterday after I ate foe spicy food" o "I had a HA yesterday, but I took some acetaminophen and it went away"

"My vision for the past 2 days has been really fuzzy"

- The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse should provide the client with which information? o 1. Glucose crosses the placenta o 2. Insulin crosses the placenta o 3. Increased caloric intake is needed o 4. Decreased caloric intake is required

1. Glucose crosses the placenta

- The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? o 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." o 2. "My insulin dose will likely need to be increased during the second and third trimesters." o 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." o 4. "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1. "I will need to increase my insulin dosage during the first 3 months of pregnancy."

o 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. § 1. Uterine tenderness § 2. Acute abdominal pain § 3. A hard, "board-like" abdomen § 4. Painless, bright red vaginal bleeding § 5. Increased uterine resting tone on fetal monitoring

1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 5. Increased uterine resting tone on fetal monitoring

- The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? o 1. Prepare the client for an ultrasound. o 2. Obtain equipment for a manual pelvic examination. o 3. Prepare to draw a hemoglobin and hematocrit blood sample o 4. Obtain equipment for external electronic fetal heart rate monitoring.

2. Obtain equipment for a manual pelvic examination.

o The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? § 1. The client is 28 years of age. § 2. This is the second pregnancy. § 3. The client has a history of hypertension. § 4. The client performs moderate exercise on a regular daily schedule.

3. The client has a history of hypertension.

- 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 should take which first action? o Administer oxygen by face mask o Clear and maintain an open airway o Administer magnesium sulfate intravenously o Assess the blood pressure and fetal heart rate

Clear and maintain an open airway

- The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? o Hematoma o Hemorrhage o Chronic HTN o Disseminated intravascular coagulation

Hemorrhage

- A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? o Urine output of 20mL o Deep tendon reflexes of 2+ o Fetal HR of 120b/min o RR of 10 breaths/min

RR of 10 breaths/min

- A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. o Proteinuria of 3+ o Urine output of 20 mL in an hour o Presence of deep tendon reflexes o Respirations of 10 breaths/min o Serum magnesium level if 4mEq/L (2mmol/L)

Urine output of 20 mL in an hour Respirations of 10 breaths/min

A nonstress test is performed on a client, and the results are documented in the chart as no accelerations during a 40-minute observation. The nurse interprets these findings as which result?

nonreactive nonstress test

o A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? § Normal test result § An abnormal test results § A high risk for fetal demise § The need for a cesarean section

normal test result

- The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. o Keep the room semi-dark o Initiate seizure precautions o Pad the side rails of the bed o Avoid environmental stimulation o Allow out-of-bed activity as tolerated

o Keep the room semi-dark o Initiate seizure precautions o Pad the side rails of the bed o Avoid environmental stimulation