Nokea
A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?
- A. Abruptio placentae.
- B. Hydatidiform mole.
- C. Preterm labor.
- D. Placenta previa.
Correct Answer: A
Rationale: Abruptio placentae involves premature placental separation, linked to cocaine use, which increases vasoconstriction and hypertension. Symptoms include pain, vaginal bleeding, and fetal distress due to impaired placental function.
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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.
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.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Encourage the client to ambulate twice per day.
- D. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
Correct Answer: B
Rationale: Seizure precautions are necessary in preeclampsia due to the risk of eclampsia from uncontrolled blood pressure. Measures include bedrails padding and medication administration to reduce seizure occurrences.
A nurse is assessing a client who gave birth 12 hours ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia.
- B. Flushed face.
- C. Hypotension.
- D. Polyuria.
Correct Answer: C
Rationale: Hypotension, defined as blood pressure below 90/60 mmHg, occurs due to reduced blood volume and cardiac output in excessive postpartum bleeding, impairing adequate perfusion to organs and tissues.
A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?
- A. A yearly Pap test is recommended until 70 years of age.
- B. Pap tests are discontinued following removal of the ovaries.
- C. Avoid having sexual intercourse for 24 hours prior to the Pap test.
- D. Viral infections can be detected by a Pap test.
Correct Answer: C
Rationale: Avoiding intercourse for 24 hours minimizes contamination of cervical cells with external materials, ensuring accurate Pap test results. It is an important preparatory guideline.