Nokea
A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain. Which of the following findings is most consistent with abruptio placenta?
- A. Low uterine tone with mild vaginal bleeding.
- B. Rigid uterine tone with dark vaginal bleeding.
- C. Soft uterine tone with painless vaginal bleeding.
- D. Low uterine tone with absence of vaginal bleeding.
Correct Answer: B
Rationale: Rigid uterine tone with dark vaginal bleeding is a hallmark of abruptio placenta. The rigidity arises from blood pooling behind the placenta, causing uterine muscle contraction. Dark vaginal bleeding occurs as the blood is often concealed and clotted before expulsion.
You may also like to solve these questions
A nurse is providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include?
- A. Peanut butter sandwich.
- B. Sliced apples.
- C. Glass of skim milk.
- D. Scrambled egg.
Correct Answer: B
Rationale: Apples are low in phenylalanine, making them a safe option for individuals with phenylketonuria. They provide essential nutrients without contributing to phenylalanine accumulation.
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: Rear-facing car seats support a baby's head and spine during sudden stops or collisions. Experts recommend maintaining this position until 2 years to reduce injury risk.
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.
For each of the following potential antihypertensive medications, indicate whether it is recommended or not recommended for use in a pregnant client.
- A. Methyldopa.
- B. Lisinopril.
- C. Labetalol.
- D. Losartan.
- E. Hydralazine.
Correct Answer: A,C,E
Rationale: Methyldopa (A) is safe and effective for pregnancy-induced hypertension. Labetalol (C) is recommended for hypertensive crises with a favorable safety profile. Hydralazine (E) is safe for severe hypertensive emergencies. Lisinopril (B) and Losartan (D) are contraindicated due to teratogenic risks.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?
- A. BUN level of 30 mg/dL (normal range: 10 to 20 mg/dL).
- B. Hemoglobin level of 9.9 g/dL (normal range: 11 to 16 g/dL).
- C. Serum uric acid level of 2.5 mg/dL (normal range: 2.7 to 7.3 mg/dL).
- D. Casual blood glucose level of 228 mg/dL (normal range: less than 200 mg/dL).
Correct Answer: A
Rationale: A BUN level of 30 mg/dL is above the normal range of 10 to 20 mg/dL. Elevated BUN is consistent with renal involvement in preeclampsia, which is caused by vascular constriction and reduced renal perfusion.