Nokea
The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might result in which problems? (Select all that apply.)
- A. Disruption of family roles
- B. Financial pressures
- C. Excessive attachment to infant
- D. Frustration with activity restriction
- E. Alteration in child care practices
Correct Answer: A,B,D,E
Rationale: High-risk pregnancies may produce problems such as disruption of family roles, financial pressures, delayed attachment to the infant, alteration in child care practices, and frustration with activity restriction.
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A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.)
- A. Privacy
- B. An opportunity to hold the infant
- C. Materials about support groups
- D. A memento (footprint or lock of hair)
- E. A warm beverage
Correct Answer: A,B,C,D
Rationale: The patient should be offered privacy, an opportunity to hold the infant, support group information, and a memento. A warm beverage is not a priority at this time.
A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.)
- A. Tell the husband that authorities will be notified immediately.
- B. Provide privacy for the assessment.
- C. Determine if children are being hurt.
- D. Communicate in a nonjudgmental way.
- E. Determine factors that increase the risk of injury.
Correct Answer: B,C,D,E
Rationale: The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The nurse also determines whether children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she intends to leave.
What symptom presented by a pregnant woman is indicative of abruptio placentae?
- A. Painless vaginal bleeding
- B. Uterine irritability with contractions
- C. Vaginal bleeding and back pain
- D. Premature rupture of membranes
Correct Answer: C
Rationale: Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae.
What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient?
- A. Ergonovine maleate (Ergotrate)
- B. Oxytocin
- C. Calcium gluconate
- D. Hydralazine (Apresoline)
Correct Answer: C
Rationale: Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a woman receives magnesium sulfate.
The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.)
- A. Toxoplasmosis
- B. Toxemia
- C. Cytomegalovirus
- D. Rubella
- E. Herpes simplex
Correct Answer: A,C,D,E
Rationale: The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.