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The nurse is caring for a client in the third trimester reporting severe right upper quadrant pain and nausea. What condition should the nurse suspect?
- A. Placenta previa.
- B. HELLP syndrome.
- C. Hyperemesis gravidarum.
- D. Abruptio placentae.
Correct Answer: B
Rationale: The correct answer is B: HELLP syndrome. In the third trimester, severe right upper quadrant pain and nausea can indicate HELLP syndrome, a serious pregnancy complication involving hemolysis, elevated liver enzymes, and low platelet count. The pain and nausea are due to liver and gallbladder involvement. Placenta previa typically presents with painless vaginal bleeding, not upper quadrant pain. Hyperemesis gravidarum causes severe nausea and vomiting but not specific upper quadrant pain. Abruptio placentae presents with sudden-onset abdominal pain and vaginal bleeding.
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During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices:
A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue.
B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern.
C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.
While evaluating the reflexes of the newborn, the nurse notes that with a loud noise the newborn symmetrically abduct and extend his arms, his fingers fan out and forms a c with the thumb and forefinger. What does the nurse document?
- A. Positive Moro reflex
- B. Positive Babinski reflex
- C. Rooting reflex
- D. Tonic neck reflex
Correct Answer: A
Rationale: The correct answer is A: Positive Moro reflex. The Moro reflex is elicited by a sudden loud noise or a jarring movement. The newborn symmetrically abducts and extends their arms, followed by fanning out their fingers and forming a "C" shape with the thumb and forefinger. This reflex is an involuntary response that indicates the normal development of the newborn's nervous system. The other choices are incorrect because:
B: Positive Babinski reflex is elicited by stroking the sole of the foot, resulting in the toes fanning out and big toe dorsiflexing.
C: Rooting reflex is elicited by touching the newborn's cheek, causing them to turn their head towards the stimulus and open their mouth to seek food.
D: Tonic neck reflex is elicited by turning the newborn's head to one side, causing extension of the arm on that side and flexion of the opposite arm.
Which assessment finding indicates uterine rupture?
- A. Contractions abruptly stop during labor
- B. Decreased maternal heart rate
- C. Gradual onset of mild pain during contractions
- D. Uterus becomes firm between contractions
Correct Answer: A
Rationale: The correct answer is A: Contractions abruptly stop during labor. Uterine rupture is a serious obstetric emergency where the integrity of the uterus is compromised, leading to potential life-threatening complications for both the mother and the fetus. When the uterus ruptures, contractions may abruptly stop due to the loss of muscle tone and coordination. This sudden cessation of contractions is a red flag indicating uterine rupture.
Choice B, decreased maternal heart rate, is not typically associated with uterine rupture. Choice C, gradual onset of mild pain during contractions, is more indicative of a normal labor process rather than uterine rupture. Choice D, uterus becomes firm between contractions, is not a specific sign of uterine rupture as it can occur in normal labor as well.
The nurse is assessing a client in the active stage of labor. Which findings indicate to the nurse that the client is beginning the second stage of labor?
- A. The membranes have ruptured.
- B. The cervix is dilated completely.
- C. The client begins to expel clear vaginal fluid.
- D. The spontaneous urge to push is initiated from perineal pressure.
Correct Answer: B
Rationale: The correct answer is B because complete dilation of the cervix marks the transition from the first to the second stage of labor. This indicates that the client is ready to start pushing the baby out. Choice A is incorrect as ruptured membranes can occur in any stage of labor. Choice C is incorrect as clear vaginal fluid expulsion is not a specific indicator of the second stage. Choice D is incorrect as the urge to push can be experienced in the first stage as well.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Document the findings and continue to monitor the client.
- B. Notify the client's provider.
- C. Increase the frequency of fundal massage.
- D. Encourage the client to empty her bladder.
Correct Answer: A
Rationale: The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition.
Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline.
Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone.
Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.