QUESTIONS AND DETAILED ANSWERS/ALREADY
GRADED A+
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment
finding is most indicative of an impending convulsion? - CORRECT ANSWER-
Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early
warning sign of an impending convulsion (eclampsia) and requires immediate
attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is
most important for the nurse to report to the healthcare provider immediately? -
CORRECT ANSWER-Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants
to use herbal therapy. Which response is best for the nurse to provide? -
CORRECT ANSWER-It is important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is
referred to a healthcare provider for a fertility workup and a
hysterosalpingography is scheduled. Which postprocedure complaint indicates
that the fallopian tubes are patent? - CORRECT ANSWER-If the tubes are patent
,(open), pain is referred to the shoulder (C) from a subdiaphragmatic collection of
peritoneal dye/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet
underneath her buttock. The nurse notes that both perineal pads are completely
saturated and the client is lying in a 6-inch diameter pool of blood. Which action
should the nurse implement next? - CORRECT ANSWER-Palpate the firmness of
the fundus.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has
increased from small to large and her fundus is boggy despite massage. The
client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare
provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take
immediately? - CORRECT ANSWER-Methergine is contraindicated for clients
with elevated blood pressure, so the nurse should contact the healthcare provider
and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of
pedal edema, dyspnea, fatigue, and a moist cough. Which question is most
important for the nurse to ask this client? - CORRECT ANSWER-Do you have a
history of rheumatic fever? Clients with a history of rheumatic fever (D) may
develop mitral valve prolapse, which increases the risk for cardiac
decompensation due to the increased blood volume that occurs during
pregnancy, so obtaining information about this client's health history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment
labor. Which adverse effect should the nurse monitor for during the infusion of
Pitocin? - CORRECT ANSWER-Pitocin causes the uterine myofibril to contract, so
,unless the infusion is closely monitored, the client is at risk for hyperstimulation
(B) which can lead to tetanic contractions, uterine rupture, and fetal distress or
demise.
The nurse observes a new mother avoiding eye contact with her newborn. Which
action should the nurse take? - CORRECT ANSWER-Observe the mother for
other attachment behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein
testing is recommended for which purpose? - CORRECT ANSWER-Screen for
neural tube defects.
What action should the nurse implement to decrease the client's risk for
hemorrhage after a cesarean section? - CORRECT ANSWER-Check the firmness
of the uterus every 15 minutes.
The nurse attempts to help an unmarried teenager deal with her feelings
following a spontaneous abortion at 8-weeks gestation. What type of emotional
response should the nurse anticipate? - CORRECT ANSWER-Grief related to her
perceptions about the loss of this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn
nursery. Which assessment finding should the nurse report to the healthcare
provider? - CORRECT ANSWER-Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that
she and her husband consider attending childbirth preparation classes. When is
, the best time for the couple to attend these classes? - CORRECT ANSWER-At 30-
weeks gestation is closest to the time parents would be ready for such classes.
Learning is facilitated by an interested pupil! The couple is most interested in
childbirth toward the end of the pregnancy when they are psychologically ready
for the termination of the pregnancy, and the birth of their child is an immediate
concern.
A 35-year-old primigravida client with severe preeclampsia is receiving
magnesium sulfate via continuous IV infusion. Which assessment data indicates to
the nurse that the client is experiencing magnesium sulfate toxicity? - CORRECT
ANSWER-Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours
(D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are
cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which
information should the nurse provide the client? - CORRECT ANSWER-
Encourage healthy lifestyles for families desiring pregnancy. Planning for
pregnancy begins with healthy lifestyles in the family (D) which is an intervention
in preconception care that targets an overall goal for a client preparing for
pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit
after a non-stress test indicated that the fetus is experiencing some difficulties in
utero. Which diagnostic test should the nurse prepare the client for additional
information about fetal status? - CORRECT ANSWER-Biophysical profile (BPP).
BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal
breathing movements, fetal movements, amniotic fluid volume, and fetal tone
and heart rate.