Placental Abnormalities
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding would the nurse expect to note if this condition is present?
1. Soft abdomen
2. Uterine tenderness
3. Absence of abdominal pain
4. Painless, bright red vaginal bleeding
2. Uterine tenderness
The clinic nurse prepares to assess a client who is in the second trimester of pregnancy. When measuring the fundal height, what should the nurse expect to note with this measurement regarding gestational age?
1. It is less than gestational age.
2. It correlates with gestational age.
3. It is greater than gestational age.
4. It has no correlation with gestational age.
2. It correlates with gestational age.
The nurse is caring for a client diagnosed with preeclampsia. When the client’s condition progresses from preeclampsia to eclampsia, what shoul the nurse’s first action be?
1. Maintain an open airway.
2. Administer oxygen by face mask.
3. Assess the maternal blood pressure and fetal heart tones.
4. Administer an intravenous infusion of magnesium sulfate.
1. Maintain an open airway.
The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
1. Peeling of the skin
2. Smooth soles without creases
3. Lanugo covering the entire body
4. Vernix that covers the body in a thick layer
1. Peeling of the skin
A primary health care provider has written a prescription to administer methylergonovine maleate to a postpartum client. The nurse should contact the primary health care provider to verify the prescription if which condition is present in the mother?
1. Hypertension
2. Excessive lochia
3. Difficulty locating the uterine fundus
4. Excessive bleeding and saturation of more than one peripad per hour
1. Hypertension
16. 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?
1. Delivery of the fetus
2. Strict monitoring of intake and output
3. Complete bed rest for the remainder of the pregnancy
4. The need for weekly monitoring of coagulation studies until the time of delivery
1. Delivery of the fetus
The nurse is measuring the fundal height on a client who is 36 weeks’ gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
1. Fear
2. Anemia
3. A full bladder
4. Compression of the vena cava
4. Compression of the vena cava
A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action?
1. Monitor the fetal heart rate.
2. Notify the primary health care provider.
3. Transfer the client to the delivery room.
4. Place the client in the Trendelenburg position.
4. Place the client in the Trendelenburg position.
After assisting with a vaginal delivery, what should the nurse do to prevent heat loss via conduction in the newborn?
1. Wrap the newborn in a blanket.
2. Close the doors to the delivery room.
3. Dry the newborn with a warm blanket.
4. Place the newborn on a warm crib pad.
4. Place the newborn on a warm crib pad.
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
1. Presence of a cephalhematoma
2. Infant blood type of O negative
3. Birth weight of 8 pounds 6 ounces
4. A negative direct Coombs’ test result
1. Presence of a cephalhematoma
17. 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?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation
2. Hemorrhage
A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?
1. Edema, ketonuria, and obesity
2. Edema, tachycardia, and ketonuria
3. Glycosuria, hypertension, and obesity
4. Elevated blood pressure and proteinuria
4. Elevated blood pressure and proteinuria
The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately?
1. Document the findings.
2. Prepare for immediate birth.
3. Increase the rate of an oxytocin infusion.
4. Administer oxygen to the client via face mask.
4. Administer oxygen to the client via face mask.
The nurse monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS) should assess the infant for which manifestations? Select all that apply.
1. Cyanosis
2. Tachypnea
3. Retractions
4. Nasal flaring
5. Acrocyanosis
6. Grunting respirations
1. Cyanosis
2. Tachypnea
3. Retractions
4. Nasal flaring
6. Grunting respirations
The newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of subdural hematoma. Which intervention should the nurse implement to assess for the primary symptom associated with subdural hematoma?
1. Monitor the urine for blood.
2. Monitor the urinary output pattern.
3. Test for contractures of the extremities.
4. Test for equality of extremity reflexes.
4. Test for equality of extremity reflexes.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings would the nurse expect to note? Select all that apply.
1.Uterine rigidity
2.Uterine tenderness
3.Severe abdominal pain
4.Bright red vaginal bleeding
5.Soft, relaxed, nontender uterus
6.Fundal height may be greater than expected for gestational age
4.Bright red vaginal bleeding
5.Soft, relaxed, nontender uterus
6.Fundal height may be greater than expected for gestational age
The nurse in a maternity unit is reviewing the clients’ records. Which clients would the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.
1.A primigravida with abruptio placentae
2.A primigravida who delivered a 10-lb infant 3 hours ago
3.A gravida 2 who has just been diagnosed with dead fetus syndrome
4.A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood
5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension
1.A primigravida with abruptio placentae
3.A gravida 2 who has just been diagnosed with dead fetus syndrome
5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension
The nurse is administering magnesium sulfate to a client experiencing severe preeclampsia. What intervention should the nurse implement during the administration of magnesium sulfate for this client?
1. Schedule a daily ultrasound to assess fetal movement.
2. Schedule a nonstress test every 4 hours to assess fetal well-being.
3. Assess the client’s temperature every 2 hours because the client is at high risk for infection.
4. Assess for signs and symptoms of labor since the client’s level of consciousness may be altered.
4. Assess for signs and symptoms of labor since the client’s level of consciousness may be altered.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
1. Variability
2. Accelerations
3. Early decelerations
4. Variable decelerations
4. Variable decelerations
The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.
1. The infant exhibits dimpling of the cheeks.
2. The infant makes smacking or clicking sounds.
3. The mother’s breast gets softer during a feeding.
4. Milk drips from the mother’s breast occasionally.
5. The infant falls asleep after feeding less than 5 minutes.
6. The infant can be heard swallowing frequently during a feeding.
1. The infant exhibits dimpling of the cheeks.
2. The infant makes smacking or clicking sounds.
5. The infant falls asleep after feeding less than 5 minutes.
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply.
1. Uterine irritability
2. Uterine tenderness
3. Painless vaginal bleeding
4. Abdominal and low back pain
5. Strong and frequent contractions
6. Nonreassuring fetal heart rate patterns
1. Uterine irritability
2. Uterine tenderness
4. Abdominal and low back pain
6. Nonreassuring fetal heart rate patterns
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.
1. Perform frequent biophysical profiles.
2. Monitor for elevated serum creatinine.
3. Monitor for manifestations of infection.
4. Teach the client how to count fetal movements.
5. Use strict sterile technique for vaginal examinations.
6. Inform the client about the need for tocolytic therapy.
1. Perform frequent biophysical profiles.
3. Monitor for manifestations of infection.
4. Teach the client how to count fetal movements.
5. Use strict sterile technique for vaginal examinations.
A pregnant client at 32 weeks’ gestation is admitted to the obstetrical unit for observation after a motor vehicle crash. When the client begins experiencing slight vaginal bleeding and mild cramps, which action should the nurse take to support the viability of the fetus?
1. Insert an intravenous line and begin an infusion at 125 mL per hour.
2. Administer oxygen to the woman via a face mask at 7 to 10 L per minute.
3. Position and connect the ultrasound transducer to the external fetal monitor.
4. Position and connect a spiral electrode to the fetal monitor for internal fetal monitoring.
3. Position and connect the ultrasound transducer to the external fetal monitor.
The nurse caring for a client in labor should plan to assess the fetal heart rate (FHR) at which specific times? Select all that apply.
1. Before ambulation
2. After vaginal examination
3. After rupture of the membranes
4. Before turning the client on her side
5. Before the administration of oxytocin
1. Before ambulation
2. After vaginal examination
3. After rupture of the membranes
5. Before the administration of oxytocin
The nurse is reviewing the antenatal history of a several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply.
1. Of Asian heritage
2. Two previous miscarriages
3. Prenatal care began during the 3rd trimester
4. History of substance abuse during pregnancy
5. Dietary assessment identified poor eating habits
6. Spontaneous rupture of membranes 24 hours ago
3. Prenatal care began during the 3rd trimester
4. History of substance abuse during pregnancy
5. Dietary assessment identified poor eating habits
6. Spontaneous rupture of membranes 24 hours ago