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Terms in this set (36)
A nurse in a provider's office is reinforcing teaching to a client who is 34 weeks of gestation and at risk for placental abruption. The nurse recognizes that which of the following is the most common risk factor for abruption?
Cocaine use
Hypertension
Blunt force trauma
Cigarette smoking
hypertension
A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
Placenta previa
Prolapsed cord
Incompetent cervix
Abruptio placentae
abruptio placentae
A
nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
"There is an increased risk of introducing infection"
"This could initiate preterm labor."
This could result in profound bleeding"
"There is an increased risk of rupture of the membranes"
This could result in profound bleeding"
A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the lower left quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the client that the client has blood in the peritoneum?
Chvostek's sign
Cullen's Sign
Chadwick's sign
Goodell's sign
Cullen's Sign
A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
INcreased urine output
Vaginal discharge
Elevated blood pressure
Joint pain
elevated blood pressure
A nurse is admitting a client who has severe preeclampsia at
35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
Assess deep tendon reflexes every hour
Obtain a daily weight
Continuous fetal monitoring
Ambulate twice daily
ambulate twice daily
A nurse is admitting a client Who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse
should implement? (select all that apply)
Administer magnesium sulfate IV
Provide a dark, quiet environment
Assess respiratory status every 4 hr
Evaluate neurologic status every 8 hr
Ensure that calcium gluconate is readily available
Administer magnesium sulfate IV
Provide a dark, quiet environment
Ensure that calcium gluconate is readily available
A nurse is caring for a client who is 28
weeks and received terbutaline. Which of the following findings should the nurse expect?
Fetal heart rate 100/min
Weakened uterine contractions
Enhanced production of fetal lung surfactant
Maternal blood glucose of 63 mg/dL
weakened uterine contractions
A nurse is caring for a client Who is suspected of having hydatidiform mole. Which of the following findings should the nurse expect to observe in
this client is?
Rapid decline in human chorionic gonadotropin (hCG) levels
Profuse, clear vaginal discharge
Irregular fetal heart rate
Excessive uterine enlargement
Excessive uterine enlargement
A nurse is admitting a client who is at 30 weeks of gestation and is preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse
should provide which of the following explanations?
"It is used to stop preterm labor contractions"
" it halts cervical dilation"
"It promotes fetal lung maturity"
" it increases the fetal heart rate."
"It promotes fetal lung maturity"
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks gestation with a diagnosis of preeclampsia.
Which of the following findings should the nurse identify as inconsistent with preeclampsia?
1+ pitting sacral edema
3+ protein in the urine
Blood pressure 148/98 mm Hg
Deep tendon reflexes of +1
Deep tendon reflexes of +1
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2g/hr. Which of the following findings indicates that it is safe for the nurse
to continue the infusion?
Diminished deep-tendon reflexes
Respiratory rate of 16/min
Urine output of 50 mL in 4 hr
Heart rate of 56/min
respiratory rate of 16/min
A nurse is admitting a client who is at 33 weeks of gestation and as a diagnosis of placenta previa. Which of the following is the priority nursing action?
Monitor vaginal bleeding
Administer glucocorticoids
Insert and IV
catheter
Apply an external fetal monitor
Apply an external fetal monitor
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
A client who is at 38 weeks of gestation and reports a cough and fever
A client who has missed a period and reports vaginal spotting
A client who is 14 weeks of gestation and reports nausea and vomiting
A client who
is at 28 weeks of gestation and reports painless vaginal bleeding
A client who is at 28 weeks of gestation and reports painless vaginal bleeding
A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?
Abruptio placentae
Placenta previa
Precipitous
labor
Threatend abortion
placenta previa
A client is admitted to the maternity unit who is 38 weeks gestation and experiencing polyhydramnios. The nurse understands that this diagnosis means that
The client is carrying more than fetus
There is an elevated level of alpha-fetoprotein in the amniotic fluid
An excessive amount of amniotic fluid is present
The fetus is likely to have a congenital
anomaly, be growth restricted, or demonstrate fetal distress during labor.
An excessive amount of amniotic fluid is present
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and as a large amount of painless,bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are:
blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4 celsius (97.6 fahrenheit). Which of the following is the priority nursing action?
Insert an indwelling urinary catheter
Initiate IV access
Witness the signature for informed consent for surgery
Prepare the abdominal and perineal areas
Initiate IV access
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 client who is experiencing fetal death at 32 weeks of gestation
A client who is experiencing preterm labor at 26 weeks of gestation
A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
A client who has a post-term pregnancy at 42 weeks of gestation
A client who is experiencing preterm labor at 26 weeks of gestation
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
Anaphylactoid syndrome of pregnancy
Disseminated intravascular coagulation
Preeclampsia
Puerperal infection
Disseminated intravascular coagulation
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?
Hypoglycemia
Hypomagnesemia
Hyperbilirubinemia
Hypocalcemia
Hypoglycemia
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has
severe preeclampsia. Which of the following is an expected finding?
Tachycardia
Absence of clonus
Polyuria
Report of headache
Report of headache
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)
Prostaglandin E2
Indomethacin
Magnesium
sulfate
Methylergonovine
Oxytocin
Indomethacin
Magnesium sulfate
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
Severe nausea and vomiting
Large amount of vaginal bleeding
Unilateral, cramp-like abdominal pain
Uterine enlargement greater
than expected for gestational age
Unilateral, cramp-like abdominal pain
A nurse in a prenatal clinic is caring for a client who is at 38 week of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse
should explain to the client that the purpose of the ultrasound is to determine which of the following?
Fetal lung maturity
Location of the placenta
Viability of the fetus
The biparietal diameter
Location of the placenta
A nurse is caring for a client who is at 36 weeks of gestation and who has suspected placenta previa. Which of the following findings support this diagnosis?
Painless red vaginal
bleeding
Increasing abdominal pain with a non relaxed uterus
Abdominal pain with scant red vaginal bleeding
Intermittent abdominal pain following passage of bloody mucus
painless red vaginal bleeding
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following
actions should the nurse take?
Discontinue the medication infusion
Prepare for an emergency c-section
Assess maternal blood glucose
Place the client in Trendelenburg position
Discontinue the medication infusion
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this
client?
Temperature
Fetal heart rate
Bowel sounds
Respiratory rate
respiratory rate
A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the
client?
Acarbose
Repaglinide
Glyburide
Glipizide
Glyburide
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 heart rate 156/min
Urinary output 40 ml in 2 hr
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
Respiratory depression
Facial flushing
Nausea
Drowsiness
Respiratory depression
A nurse is caring for a client who is in
premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
Headaches
Nervousness
Tremors
Dyspnea
dyspnea
A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta
previa. Which of the following is an appropriate nursing action?
Examination to determine cervical status
A magnesium sulfate infusion
Initiation of pushing
Preparation for c-section
preparation for a c-section
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse
offer??
" you must be feeling scared and powerless"
" everyone worries about her baby when she's in labor"
" your pregnancy is advanced so your baby should be fine"
" we have a neonatal unit here that's equipped to handle emergencies"
" you must be feeling scared and powerless"
A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal
bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
Administer oxygen via nasal cannula
Offer option to view products of conception
Instruct the client to increase potassium-rich foods in the diet
Maintain the client on bed rest
Offer option to view products of conception
A nurse is completing discharge
teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?
Consume 40-50 g of protein daily
Avoid salting of foods during cooking
Drink 48-64 ounces of water daily
Limit intake of whole grains, raw fruits, and vegetables
Drink 48-64 ounces of water daily
A nurse in the ambulatory surgery center
is providing discharge teaching to a client who had dialtion and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
Vaginal intercourse can be resumed after 2 weeks
Products of conception will be present in vaginal bleeding
Increased intake of zinc-rich foods is recommended
Aspirin may be taken for cramps
Vaginal intercourse can be resumed after 2 weeks
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