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4 minutes after the birth of the baby there is a sudden gush of blood from the mom's vagina and the about 8 inches of umbilical cord slides out. What action should nurse take first?
- A. Watch for emergence of placenta
- B. Assess for signs of uterine inversion
- C. Perform fundal massage
- D. Prepare for possible episiotomy repair
Correct Answer: A
Rationale: In this situation, the nurse should first watch for the emergence of the placenta. This is because the gush of blood followed by the umbilical cord slipping out indicates a possible placental abruption, where the placenta separates from the uterine wall before the baby is born. It is crucial to closely monitor the situation for signs of an incomplete placental delivery or any further complications. If the placenta does not deliver within a reasonable timeframe or if there are signs of excessive bleeding or other issues, immediate medical intervention may be necessary.
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Medication that are contraindicated for management of PPH include SATA (Cytotec, Hemabate, Pitocin, Methergine all for PPH)
- A. Terbutaline (for preterm labor)
- B. Magnesium sulfate
- C. Methergine
- D. Pitocin
Correct Answer: A
Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma regain
- C. Prothrombin time
- D. Urine culture
Correct Answer: A
Rationale: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. One important laboratory test that the nurse should anticipate for a client with hyperemesis gravidarum is the urine ketones test. Ketones in the urine can indicate that the body is breaking down fat for energy instead of using glucose, which can occur during prolonged fasting or in conditions like hyperemesis gravidarum where there is severe vomiting leading to inadequate intake of nutrients. Monitoring urine ketones levels helps healthcare providers assess the severity of dehydration and metabolic derangement in these patients. It guides the management of fluid and electrolyte replacement to prevent complications like ketosis and metabolic acidosis.
The nurse is caring for a client at 38 weeks' gestation reporting decreased fetal movement. What is the priority action?
- A. Perform a nonstress test.
- B. Instruct the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: A nonstress test is the first step to assess fetal well-being in cases of decreased fetal movement.
A patient who is older than 35 years may have difficulty achieving pregnancy because
- A. prepregnancy medical attention is lacking.
- B. personal risk behaviors influence fertility.
- C. contraceptives have been used for an extended period of time.
- D. the ovaries may be affected by the normal aging process.
Correct Answer: D
Rationale: As women age, their ovarian reserve decreases and the quality of their eggs declines, making it more difficult to conceive. This is due to the normal aging process of the ovaries, which can lead to decreased fertility and an increased risk of chromosomal abnormalities in the embryos. Therefore, a patient who is older than 35 years may have difficulty achieving pregnancy because the ovaries may be affected by the normal aging process.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension as a common complication. This occurs because the local anesthetic affects the sympathetic nerves, leading to vasodilation and subsequent lowering of blood pressure. It is crucial for nurses to monitor the client's blood pressure closely and be prepared to administer IV fluids or medications to address the hypotension promptly. Vomiting, tachycardia, and respiratory depression are not typically associated with epidural anesthesia; therefore, hypotension is the most likely complication to be identified in this scenario.