Goodwin College- NUR 210: ATI Quiz 4 WEEK 5; Complete Questions and Answers updated 2025.

ATI Quiz 4 WEEK 5 Q 1. A nurse in the ER caring for client who comes to the ER reporting severe abdominal pain on LLQ. Provider suspects rupture ectopic pregnancy. Which indicates that there is blood in the peritoneum? Chvostek Sign Cullen sign Chadwick sign Goodell sign Q 2. A nurse in the antepartum unit is caring for a client who is 36 wks. gestation and has pregnancy induced HTN. Suddenly reports abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? Placenta previa- Placenta previa occurs with painless vaginal bleeding during the second and third trimester. Prolapsed cord- A prolapsed umbilical cord occurs when the cord lies below the presenting fetal part. It might be visible or palpable with a vaginal exam. There might be changes to the fetal heart rate tracing. Incompetent cervix- An incompetent cervix is a cause of late miscarriage. It results in painless, passive dilation of the cervix during the second trimester of pregnancy. Abruptio placentae Q 3. A nurse is admitting a client who is at 38 weeks of gestation and has severe pre-eclampsia. When assessing the client, the nurse should expect which of the following findings? Tachycardia 1 Absence of clonus- presence of clonus and brisk DTR- 3+, 4+ Polyuria- present of proteinuria and decreased urine output report of Headache Q 4. A nurse caring for client who has suspected ectopic pregnancy at 8 weeks gestation. Which manifestation should the nurse expect to identify as consistent with the diagnosis? Severe N & V- Severe vomiting is consistent with a diagnosis of hyperemesis gravidarum. Large amount of Vaginal Bleeding Uterine enlargement greater than expected for gestational age. Unilateral, cramp like abdominal painRationale: An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix. Q 5. 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 past 30 min. Nurse suspects placenta previa. Which is appropriate nursing actions? Examination to determine cervical status. A magnesium sulfate infusion- Magnesium sulfate infusions are indicated for the treatment of preterm labor or the prevention of seizures in the preeclamptic client. The therapeutic action is smooth muscle relaxation. Initiation of pushing- All clients with a confirmed placenta previa must deliver via cesarean section. Preparation for C sec birth 2 Q 6. A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarium. Which nurse expects? SATA History of migraine Nulliparous Twin gestations. History of gestational hypertension Oligohydramnios Q 7. A nurse in a prenatal clinic is teaching a client Who is in her second trimester and has a new diagnosis of gestational diabetes. Which statement needs further teaching? I will reduce my exercise schedule to 3 days a week." I should limit my carb to 50 % of caloric intake. I will take my glyburide with breakfast. I know I am at increased risk to develop type 2 Diabetes. Q 8. A nurse is competing discharge teaching to a client who is 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 g to 50 g of protein daily. Avoid Salting of foods during cooking- The client who has preeclampsia is instructed to salt foods to taste, and limit consumption of foods that are high in sodium, such as chips, pretzels, processed meats, and pickles. Drink 48 to 64 ounces of water daily. Limit intake of whole grains, raw fruits, and vegetables. Q 9. 22 weeks’ gestation, unable to control diabetes with diet and exercise. Prescription from the provider- Acarbose 3 Repaglinide Glipizide Insulin Q 10. A nurse is admitting a client Who has severe preeclampsia at 35 weeks. Which order requires clarification? Assess deep tendon reflexes every hour. Obtain a daily weight. Continuous Fetal Monitoring. Ambulate twice daily. Q 11. A nurse is admitting a client Who is 30 weeks of gestation and is in preterm labor. New prescription for betamethasone and asks nurse the purpose of this medication? It is used to stop preterm labor contraction. It halts cervical dilation. It promotes fetal lung maturity. - Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant. It increases the FHR. Q 12. 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: Prostaglandin E 2- used for cervical ripening. Indomethacin Magnesium sulfate Methylergonovine- Methylergonovine promotes uterine contractions to manage postpartum hemorrhage. 4 Oxytocin- Oxytocin is used to induce and augment labor. Q 13. A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which should nurse provide? The infection is treated with one dose of azithromycin. - or doxycycline bid x 7 d If your sexual partner has no symptoms, no medication is needed. Treat all sexual partners. You must avoid sexual relation for 3 days. - until antibiotic completed/ 7days You need to return in 6 mo. for retesting- testing in 3 mo. Q 14. A nurse is caring for an adolescent client who is gravida 1 and para 0. Client admitted to hospital at 38 weeks with dx of preeclampsia, which findings is inconsistent with preeclampsia? 1+ pitting sacral edema Deep tenson Reflex +1 3+ protein in urine BP 148/98 mm Hg Q 15. A nurse is caring for a client Who is preterm labor at 32 weeks gestation. Client asks, "will my baby be okay"? which should nurse offer? You must be feeling scared and powerless?- open- end statements. Everyone worries about her when she is in labor. Your pregnancy is advanced so your baby should be fine. We have a neonatal unit here that’s equipped to handle emergencies. Q 16. A nurse is assessing a client Who is pregnant for preeclampsia. Which finding should indicate further evaluation is needed? Increased urine output Vaginal discharge Elevated blood pressure 5 Joint pain Q 17. A nurse is admitting a client Who is at 37 weeks of gestation and has severe gestational hypertension. Nurse should implement? Sata Administer mag sulfate IV Provide a dark, quiet environment. Ensure that calcium Gluconate is readily available. Assess respiratory status every 4 h Evaluate neurologic status every 8 hr. Q 18. A nurse is assessing a client Who is receiving magnesium sulfate to treat preeclampsia. Which should you report to provider? Respirations 16/min Headache for 30 min Urinary output 40 mL in 2 hr. Fetal heart rate 158/min Q 19. A nurse is assessing a client who received mag sulfate to treat preterm labor. Which foll indicates toxicity of magnesium sulfate and report to the provider? Respiratory depression Facial flushing Nausea Drowsiness Q 20. A nurse is admitting a client who is at 33 weeks’ gestation and has a diagnosis of placenta Previa. Nursing action? Monitor vaginal bleeding. 6 Administer glucocorticoids. Insert an IV catheter. Apply an external fetal monitor. Q 21. A nurse is caring for a client Who has preeclampsia and is being treated with mag sulfate IV, RR- 10/min and DTR are absent. Which action? Discontinue the medication infusion. Prepare for an emergency cesarean birth. Assess maternal blood glucose. Place the client in Trendelenburg position. Q 22. A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Priority assessment? Respiratory rate Temperature Fetal heart rate (FHR Bowel sounds Q 23. A nurse is caring for a client Who is 30 weeks of gestation and has placenta previa. Client asks why provider does not do an internal exam. Primary reason nurse should 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." 7 Q 24. A nurse is caring for a client Who has severe preeclampsia and is receiving mag sulfate IV at 2g/hr. which is safe for nurse to continue the infusion? Diminished deep tendon reflexes. Respiratory rate of 16/min Urine output of 50 mL in 4hr Heart rate of 56/min Q 25. A nurse is caring for a client Who is at 36 weeks of gestation. And who has a suspected placenta Previa. Which of the following finding support this? Painless red vaginal bleeding Increasing abdominal pain with a nonrelated uterus Abdominal pain with scant red vaginal bleeding Intermittent abdominal pain following passage of bloody mucus. Q 26. nurse is planning came for a client who is at 10 weeks 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 your plan of care? offer option to view products of conception. administer oxygen via nasal cannula. Instruct the client to increase potassium-rich foods in the diet. Maintain the client on bed rest. Q 27. Abdominal assessment is consistent with abruptio placentae. This client's abdomen is firm, rigid, and tender to palpation, which is caused by the premature separation or detachment of the implanted placenta from the uterus. Hemoglobin level is consistent with abruptio placentae and placentae previa. Clients who experience abruptio placentae and placentae previa are at an increased risk for hemorrhage and hypovolemia due to the blood loss associated with these conditions. This client's hemoglobin is 8 g/dL, 8 which is below the expected reference range of 12 to 16 g/dL, and is an indicator of excessive blood loss. Uterine tone is consistent with abruptio placenta. The client's abdomen is hard to palpation between contractions, which is consistent with abruptio placentae. The abdomen of a client who has placenta previa will be soft and relaxed when palpated. Abdominal pain level is consistent with an abruptio placenta. Findings associated with an abruptio placentae include moderate to severe pain. This client reports their pain as an 8 on a scale of 0 to 10. Clients who have placenta previa do not report pain. Description of vaginal bleeding is consistent with an abruptio placenta. Clients who have abruptio placentae have dark red bleeding as indicated in the client's medical record. Clients who have placenta previa present bright red vaginal bleeding. Q 28. Hematocrit level is consistent with abruptio placentae and placentae previa. Clients who experience abruptio placentae and placentae previa are at an increased risk for hemorrhage due to the blood loss associated with these conditions. This client's hematocrit is 30%, which is below the expected reference range of (> 33%) and an indicator of excessive blood loss. Uterine tone is consistent with placenta previa. The client's abdomen is soft and nontender to palpation and no contractions are observed. The abdomen of a client who has abruptio placentae will be tender and ridged when palpated and might remain hard between contractions, which indicates hypertonicity. Description of vaginal bleeding is consistent with a placenta previa. Clients who have placenta previa have painless, bright red vaginal bleeding, which is what is indicated in the client’s medical record. Clients who have abruptio placentae have dark red vaginal bleeding. Client's pain level is consistent with placenta previa. The client denies pain and contractions and reports that their abdomen is not tender when palpated. The client who has abruptio placentae will report moderate to severe pain as well as abdominal tenderness upon palpation. Fundal height is consistent with placenta previa and abruptio placentae. The client who has placenta previa might have an increased fundal height because the placenta rests in the lower uterine segment causing the fetus to position itself higher in the uterus. The client who has abruptio placenta might have an increased fundal height due to covert 9 bleeding. Serial fundal height measurements might be prescribed to assess for continued bleeding. Q 29. Vaginal examination is consistent with preterm labor. The client who is at 33 weeks of gestation should have not have cervical dilation. However, the client is dilated 2 cm, is 100% effaced and at 0 station, which should indicate to the nurse that the client is experiencing preterm labor. Pain is consistent with preterm labor and urinary tract infection. Clients who have preterm labor frequently have constant, low dull back pain and mild, low abdominal cramping. Clients who have a urinary tract infection can have back pain, urinary frequency, burning with urination, and lower abdominal and suprapubic pain. Type of vaginal discharge is consistent with preterm labor. The nurse had bloody mucous noted on the sterile glove after checking the client's cervical dilation. This type of discharge is consistent with preterm labor and occurs because of cervical dilation. Temperature is consistent with a urinary tract infection. This client has a temperature of 38.1 °C (100.5 °F). The nurse should identify that fever, frequency, urgency, and burning with urination are findings associated with a urinary tract infection. 10