Nokea
The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?
- A. Painless vaginal bleeding.
- B. Hard, rigid abdomen with severe pain.
- C. Clear amniotic fluid.
- D. Regular uterine contractions.
Correct Answer: B
Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.
You may also like to solve these questions
The nurse is assessing a client at 36 weeks' gestation who reports swelling in the hands and face. What is the priority nursing action?
- A. Check the client’s blood pressure.
- B. Reassure the client that swelling is normal.
- C. Encourage the client to reduce salt intake.
- D. Evaluate the fetal heart rate.
Correct Answer: A
Rationale: Swelling in the hands and face may indicate preeclampsia, requiring immediate blood pressure assessment.
A patient is about to undergo an amniocentesis. tion on her postpartum clients. Which client has a Which procedures should the nurse perform? Select high risk for postpartum hemorrhage? Select all all that apply.
- A. Have the patient give verbal consent for the
- B. Client who delivered vaginally at 40 weeks procedure.
- C. Client who delivered by cesarean delivery because
- D. Assess for bleeding disorders.
Correct Answer: A
Rationale: Having the patient give verbal consent for the procedure is a standard practice and an important step to ensure that the patient understands the risks and benefits of the amniocentesis.
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
- A. Blood pressure 142/92 mm Hg
- B. Urine output 100 mL in hr.
- C. Pulse 58/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: Methylergonovine is a medication used to help contract the uterus and control postpartum hemorrhage. One of its side effects is vasoconstriction, which can lead to increased blood pressure. The client's blood pressure of 142/92 mm Hg is elevated, and administering methylergonovine could further increase the blood pressure, potentially causing harm to the client. It is important to withhold the medication in this situation to prevent worsening of hypertension. The other assessment findings are within normal ranges and do not contraindicate the administration of methylergonovine.
A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36C and a persisting oxygen saturation of <87%. The nurse interprets these findings as:
- A. Cardiac distress
- B. Respiratory Alkalosis
- C. Bronchial pneumonia
- D. Respiratory Distress
Correct Answer: D
Rationale: The newborn's presentation with a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, and persisting low oxygen saturation (<87%) are indicative of respiratory distress. These signs suggest that the newborn is having difficulty breathing and may not be getting enough oxygen into their system. Respiratory distress in newborns is a serious condition that requires immediate attention and intervention to support breathing and oxygenation. It is crucial for healthcare providers to recognize and address respiratory distress promptly to prevent further complications.
A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include?
- A. Focusing on controlling body functions
- B. "Synchronized breathing will be required during hypnosis"
- C. "Hypnosis can be beneficial in you practiced it during the prenatal period"
- D. "Hypnosis does not work for controlling pain associated with labor".
Correct Answer: C
Rationale: The correct information that the nurse should include is that "Hypnosis can be beneficial if you practiced it during the prenatal period." This statement is true because hypnosis is a tool that can help individuals manage pain and stress through focused attention and suggestion. By practicing hypnosis techniques during the prenatal period, the individual can become more familiar and comfortable with the practice, making it more effective during labor. It is important to establish a routine and practice hypnosis consistently to maximize its benefits during labor.