Nokea
Client reports intermittent dark brown vaginal discharge for the past three days.
A client reports an intermittent dark brown vaginal discharge for the past three days. What should the nurse do?
- A. The nurse should assess the client for signs of molar pregnancy.
- B. The nurse should evaluate the risk for hypovolemic shock due to blood loss.
- C. The nurse should ensure appropriate laboratory testing for the diagnosis of choriocarcinoma.
- D. The nurse should prioritize preparing the client for suction and curettage.
Correct Answer: A
Rationale: Molar pregnancy often manifests as intermittent dark brown vaginal discharge due to trophoblastic tissue expulsion. It warrants assessment as it correlates with hCG elevation and abnormal placental development.
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Client in active labor with early decelerations of the FHR on the fetal monitor tracing.
A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.
Client being admitted for induction of labor.
A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby in any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: Checking the identification badge ensures the individual removing the baby is authorized, reducing the risk of abduction. This is a recommended safety practice in hospital settings to protect newborns.
Drag words from the choices below to fill in each blank in the following sentence: The nurse should [option] as a potential complication.
- A. The nurse should plan to discuss with the client the risk for hypothyroidism.
- B. The nurse should include fallopian tube rupture as a potential complication.
- C. The nurse should explain hypovolemic shock as a life-threatening risk.
- D. The nurse should elaborate on the development of an invasive mole.
Correct Answer: B
Rationale: Fallopian tube rupture is a critical complication of conditions like ectopic pregnancy, emphasizing the importance of timely diagnosis and intervention to prevent life-threatening internal bleeding and sepsis.
Client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections.
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The abdomen is the preferred site for subcutaneous heparin injections due to its fatty tissue, which minimizes risks of intramuscular bleeding and ensures consistent drug absorption.
Client at 34 weeks of gestation scheduled for a nonstress test.
A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?
- A. You will receive a medication through an IV for this test.
- B. You should expect the test to take about 30 minutes.
- C. You should not eat or drink for 4 hours prior to the test.
- D. This test will help determine if your baby's lungs are mature.
Correct Answer: B
Rationale: Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.