Nokea
A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
- A. Placenta previa
- B. Prolapsed cord
- C. Incompetent cervix
- D. Abruptio placentae
Correct Answer: D
Rationale: The correct answer is D, abruptio placentae. This condition is characterized by sudden onset of continuous abdominal pain and vaginal bleeding, common at 36 weeks gestation with pregnancy-induced hypertension. It occurs when the placenta prematurely separates from the uterine wall. Placenta previa (A) presents painless bleeding, prolapsed cord (B) involves cord presenting before the fetus, and incompetent cervix (C) leads to painless dilation of the cervix. Thus, abruptio placentae is the most likely complication in this scenario.
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A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
- A. Fetal attitude is in general flexion.
- B. Fetal lie is longitudinal.
- C. Maternal pelvis is gynecoid.
- D. Fetal position is persistent occiput posterior.
Correct Answer: D
Rationale: The correct answer is D: Fetal position is persistent occiput posterior. This position, where the baby's head is facing the mother's abdomen instead of her back, can lead to severe backache and difficulty during labor due to increased pressure on the mother's spine. This malposition can impede the progress of labor and cause prolonged labor.
Explanation of incorrect choices:
A: Fetal attitude in general flexion is a normal position and not typically associated with severe backache.
B: Fetal lie being longitudinal refers to the baby's position in relation to the mother's spine and is not directly related to backache.
C: Maternal pelvis being gynecoid is a favorable shape for childbirth and is unlikely to cause severe backache during labor.
A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is a sign that precedes labor as the body may experience a burst of energy known as the "nesting instinct." This surge can occur as the body prepares for the upcoming physical demands of labor.
A: Decreased vaginal discharge is not a sign of impending labor; in fact, there may be an increase in vaginal discharge as the body prepares for childbirth.
C: Urinary retention is not a sign of impending labor and can be a symptom of other issues such as a urinary tract infection.
D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor approaching; weight fluctuations during pregnancy are common and can vary based on various factors.
A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?
- A. These exercises facilitate preventing constipation.
- B. These exercises aid pelvic muscle stretching during birth.
- C. They assist in decreasing backaches.
- D. They can prevent additional stretch marks.
Correct Answer: B
Rationale: The correct answer is B because Kegel exercises help strengthen the pelvic floor muscles, which can aid in pelvic muscle stretching during birth. This can potentially reduce the risk of pelvic floor dysfunction postpartum.
A is incorrect because Kegel exercises do not directly prevent constipation.
C is incorrect because while Kegel exercises may indirectly help with backaches by improving pelvic floor muscle support, they are not specifically targeted for backache relief.
D is incorrect as Kegel exercises do not prevent stretch marks, as stretch marks are related to skin elasticity rather than muscle tone.
During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?
- A. Acrocyanosis of hands and feet
- B. Anterior fontanel soft and level
- C. Plantar creases cover 2/3 of sole
- D. Vernix caseosa in inguinal creases
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
Plantar creases covering 2/3 of the sole is a standard newborn assessment finding indicating normal development. This is a key milestone in assessing the newborn's muscle tone and neurological status. Absence or presence of plantar creases can provide insights into potential developmental issues. Therefore, recording this finding is crucial for monitoring the newborn's growth and development.
Summary of Other Choices:
A: Acrocyanosis of hands and feet - Common benign finding in newborns due to immature circulation, not a specific part of newborn assessment.
B: Anterior fontanel soft and level - Important assessment, but not specific to gestational age assessment.
D: Vernix caseosa in inguinal creases - Normal finding, but not a specific part of gestational age assessment.
A client who is at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding, with a tentative diagnosis of inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
- A. Administer oxygen via nasal cannula.
- B. Offer the option to view products of conception.
- C. Instruct the client to increase potassium-rich foods in the diet.
- D. Maintain the client on bed rest.
Correct Answer: B
Rationale: The correct answer is B: Offer the option to view products of conception. This intervention allows the client to have closure and process the loss. It can also provide emotional support and facilitate the grieving process. Option A is not necessary unless the client is hypoxic. Option C is not relevant to the immediate management of an inevitable abortion. Option D may be advised for some clients, but it is not as crucial as offering emotional support and closure to the client in this situation.