Nokea
The experienced nurse instructs the new nurse that a vaginal examination should not be performed on the newly admitted client with possible grade 3 abruptio placentae. Which illustration shows the new nurse’s thinking about the uterus of the client with the grade 3 abruptio placentae?
- A. Illustration 1
- B. Illustration 2
- C. Illustration 3
- D. Illustration 4
Correct Answer: D
Rationale: Illustration 4 shows severe grade 3 abruptio placentae. More than 50% of the placenta separates with concealed hemorrhage. Illustration 1 shows complete placenta previa and not abruptio placentae. Illustration 2 shows partial placenta previa and not abruptio placentae. Illustration 3 shows mild grade 1 abruptio placentae. Less than 15% of the placenta separates with concealed hemorrhage.
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The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client’s parity?
Correct Answer: 1
Rationale: The client has given birth to her first child; her parity is 1.
Which of the following beverages should be included in the list of unhealthy drinks to avoid? Select all that apply.
- A. Alcohol
- B. Coffee
- C. Tea
- D. Cola beverages
- E. Sports drinks
- F. Orange juice
Correct Answer: A,B,C,D
Rationale: Alcohol is harmful to the fetus, and caffeinated drinks (coffee, tea, cola) should be limited due to potential effects on fetal development.
The client who is actively bleeding due to a spontaneous abortion asks the nurse why this is happening. The nurse advises the client that the majority of first-trimester losses are related to which problem?
- A. Cervical incompetence
- B. Chronic maternal disease
- C. Poor implantation
- D. Chromosomal abnormalities
Correct Answer: D
Rationale: Chromosomal abnormalities account for the majority of first-trimester spontaneous abortions. Cervical incompetence can result in spontaneous abortion but does not account for the majority. Chronic maternal disease can result in spontaneous abortion but does not account for the majority. Poor implantation can result in spontaneous abortion but does not account for the majority.
Which of the following should the nurse plan to have available when providing nursing care to this client? Select all that apply.
- A. I.V. start kit
- B. An intake and output record
- C. Oxygen and face mask
- D. Cardiac monitor
- E. A consent for a blood transfusion
- F. A suction machine
Correct Answer: A,B,C,F
Rationale: Hyperemesis gravidarum with dehydration requires I.V. fluids, intake/output monitoring, oxygen if needed, and suction for vomiting.
The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.
- A. “Return for a blood transfusion if bleeding continues to be dark red.”
- B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
- C. “I can make a referral to a pregnancy loss support group if you like.”
- D. “You need to use contraceptives to avoid getting pregnant for one year.”
- E. “Someone should remain with you at home for the first 12 to 24 hours.”
Correct Answer: C,E
Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.