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A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use.
- B. Blunt force trauma.
- C. Hypertension.
- D. Cigarette smoking.
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption due to the increased pressure on the placenta, leading to separation from the uterine wall. Cocaine use (A) and cigarette smoking (D) can also increase the risk but are not as common as hypertension. Blunt force trauma (B) can cause a sudden separation of the placenta but is less common compared to hypertension in a routine prenatal setting.
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A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
- A. Reddened with a small amount of bloody drainage.
- B. Pink without drainage.
- C. Reddened with a scant amount of yellow exudate.
- D. Reddened, with copious blood.
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound. Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications. Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. This is a cephalohematoma which can occur spontaneously.
- B. A caput succedaneum will subside in a few days.
- C. Mongolian spots can be found on the skin of many newborns.
- D. This is a telangiectatic nevus and no treatment is needed.
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines. Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum. Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Dyspnea
- B. Headaches
- C. Nervousness
- D. Tremors
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
- A. Large amount of vaginal bleeding
- B. Uterine enlargement greater than expected for gestational age
- C. Severe nausea and vomiting
- D. Unilateral, cramp-like abdominal pain
Correct Answer: D
Rationale: The correct answer is D. Unilateral, cramp-like abdominal pain is a classic symptom of an ectopic pregnancy. This pain occurs due to the fallopian tube stretching or rupturing as the embryo grows. This is different from a normal intrauterine pregnancy, where the pain would be central or bilateral.
A: Large amount of vaginal bleeding is not a typical symptom of an ectopic pregnancy.
B: Uterine enlargement greater than expected for gestational age would be seen in a normal intrauterine pregnancy, not an ectopic pregnancy.
C: Severe nausea and vomiting are common symptoms of early pregnancy but are not specific to ectopic pregnancy.
In summary, the key to identifying an ectopic pregnancy is recognizing the combination of abdominal pain and the location of the pain.
A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?
- A. Assess maternal blood glucose.
- B. Discontinue the magnesium infusion.
- C. Prepare for an emergency cesarean birth.
- D. Place the client in Trendelenburg position.
Correct Answer: B
Rationale: Correct Answer: B - Discontinue the magnesium infusion.
Rationale: A respiratory rate of 10/min indicates respiratory depression, a common adverse effect of magnesium sulfate. Discontinuing the infusion is crucial to prevent further respiratory compromise and potential respiratory arrest. This action takes precedence over other interventions as it addresses the immediate risk to the client's safety.
Summary of other choices:
A: Assessing maternal blood glucose is unrelated to the client's respiratory rate and immediate need for intervention.
C: Emergency cesarean birth is not indicated based solely on the respiratory rate and magnesium sulfate administration.
D: Placing the client in Trendelenburg position is not appropriate for respiratory depression and may worsen the situation.