Nokea
Which of the following conditions is concerning to The nurse recognizes which as a risk factor for placenta the infant nursery nurse? abruptio? Select all that apply.
- A. An infant who passes a thick, greenish to black
- B. Use of alcohol stool with each bowel movement
- C. Hypertension
- D. Hard, small, white papules on the face of the
Correct Answer: C
Rationale: Correct Answer: C - Hypertension
Rationale:
1. Hypertension is a known risk factor for placental abruption.
2. Hypertension can lead to poor placental perfusion, increasing the risk of abruption.
3. Proper monitoring and management of hypertension are crucial to prevent adverse outcomes.
Summary:
A, B, D are unrelated to placental abruption and not risk factors. Hypertension is directly linked to placental abruption due to its impact on placental perfusion.
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A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
- A. Respiratory depression
- B. Facial flushing
- C. Nausea
- D. Drowsiness
Correct Answer: A
Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.
The nurse is assessing a client in labor with ruptured membranes. What finding indicates the need for immediate intervention?
- A. Temperature of 100.6°F.
- B. Clear amniotic fluid.
- C. Green, foul-smelling fluid.
- D. Client reports contractions every 5 minutes.
Correct Answer: C
Rationale: The correct answer is C: Green, foul-smelling fluid. This indicates meconium-stained amniotic fluid, which can be a sign of fetal distress and possible meconium aspiration. Immediate intervention is needed to prevent potential complications for the baby.
A: Temperature of 100.6°F could indicate maternal infection but does not require immediate intervention unless other signs are present.
B: Clear amniotic fluid is a normal finding.
D: Contractions every 5 minutes may indicate active labor, but it is not an immediate concern unless coupled with other signs of distress.
The nurse is educating a client about Braxton Hicks contractions. Which statement indicates proper understanding?
- A. They are regular and increase in intensity over time.
- B. They are irregular and usually painless.
- C. They indicate that labor is starting.
- D. They require immediate medical attention.
Correct Answer: B
Rationale: The correct answer is B because Braxton Hicks contractions are indeed irregular and typically painless contractions that occur throughout pregnancy. They are considered practice contractions and do not indicate the onset of labor. Choice A is incorrect as Braxton Hicks contractions are not regular or increasing in intensity. Choice C is incorrect because Braxton Hicks contractions do not signal the start of labor. Choice D is also incorrect as Braxton Hicks contractions are a normal part of pregnancy and do not require immediate medical attention.
What is the most critical sign of fetal distress during labor?
- A. Accelerations in fetal heart rate
- B. Decreased variability in fetal heart rate
- C. Early decelerations in fetal heart rate
- D. Late decelerations in fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.
The nurse is assessing a client in the third trimester with suspected placental abruption. What finding supports this diagnosis?
- A. Painless bright red bleeding.
- B. Boardlike abdomen and severe pain.
- C. Soft, relaxed uterus.
- D. Increased fetal movement.
Correct Answer: B
Rationale: The correct answer is B: Boardlike abdomen and severe pain. This finding supports the diagnosis of placental abruption because it indicates a significant and sudden separation of the placenta from the uterine wall, leading to intense pain and rigidity of the abdomen due to internal bleeding. Painless bright red bleeding (choice A) is more indicative of placenta previa, not placental abruption. A soft, relaxed uterus (choice C) is not typical in placental abruption, which usually presents with uterine tenderness and rigidity. Increased fetal movement (choice D) is not specific to placental abruption and can occur in various pregnancy conditions.