Nokea
A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms? Select all that apply.
- A. A bleeding that is concealed or apparent.
- B. Abdominal rigidity.
- C. Painful abdomen.
- D. Painless bleeding.
- E. Large placenta.
- F. Bleeding that stops spontaneously.
Correct Answer: A,B,C
Rationale: Abruptio placentae involves placental separation, causing concealed or apparent bleeding, abdominal rigidity, and pain due to uterine irritation. Painless bleeding is characteristic of placenta previa, and large placenta or spontaneous cessation are not typical.
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A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.
The nurse is developing a plan of care for a neonate who is to undergo gastroschisis surgery. What should be included? Select all that apply.
- A. Prevention of hypothermia.
- B. Maintenance of fluid and electrolyte balance.
- C. Provision of time for parental bonding.
- D. Prevention of infection.
- E. Providing developmental care.
Correct Answer: A,B,C,D,E
Rationale: All options are critical components of care for a neonate with gastroschisis to ensure optimal outcomes before and after surgery.
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
- A. Call for immediate assistance.
- B. Turn the client to her side.
- C. Note the time when the seizure began.
- D. Maintain airway.
Correct Answer: A,D,B,C
Rationale: Call for help, ensure the airway is clear, turn the client to prevent aspiration, and document the seizure duration.
A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the physician most likely will order which of the following medications?
- A. Anticoagulants.
- B. Antibiotics.
- C. Diuretics.
- D. Folic acid supplements.
Correct Answer: B
Rationale: Prosthetic heart valves increase the risk of endocarditis during labor due to bacteremia. Prophylactic antibiotics are typically ordered. Anticoagulants may be adjusted, but antibiotics are prioritized during labor.
When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which of the following?
- A. Ectopic pregnancy.
- B. Choriocarcinoma.
- C. Multifetal pregnancies.
- D. Infertility.
Correct Answer: B
Rationale: Clients with hydatidiform moles are at risk for choriocarcinoma.