Nokea
The nurse is caring for the client with a grade 3 placental abruption. Prioritize the prescribed interventions that the nurse should implement.
- A. Obtain serum blood draw for clotting disorders
- B. Administer 1 unit whole blood
- C. Start oxygen at 2—4 liters per nasal cannula
- D. Administer lactated Ringer’s at 200 mL/hr
- E. Prepare for cesarean delivery if fetal distress
- F. Continuous external fetal monitoring
Correct Answer: C,D,F,A,B,E
Rationale: Start oxygen at 2—4 liters per nasal cannula is priority to maximize fetal oxygenation. Administer lactated Ringer’s at 200 mL/hr to treat hypovolemia, increase blood flow, and maximize oxygenation. Continuous external fetal monitoring should be performed to identify fetal distress early. Obtain serum blood draw for clotting disorders, specifically DIC. Administer 1 unit whole blood is next and will depend on the amount of blood loss. Prepare for cesarean delivery if fetal distress would be last because it would depend on the client and fetal status.
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Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
- A. A client who is pregnant for the fifth time
- B. A client who is 16 years old
- C. A client who has a history of twins in the family
- D. A client who has primary hypertensive disease
- E. A client who works 40 hours a week in a factory
- F. A client who reports spotting in the first trimester
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for which problems? Select all that apply.
- A. Susceptibility to infection
- B. Easily fatigued
- C. Increased risk for preeclampsia
- D. Increased risk of diabetes
- E. Congenital defects
Correct Answer: A,B,C
Rationale: Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. Iron-deficiency anemia is not associated with an increased risk of diabetes. Iron-deficiency anemia is not associated with an increased risk of congenital defects.
The pregnant client (G1P0) in the first trimester tells the nurse that she is anxious about losing her baby, prenatal care, and her labor and birth. Which teaching need should the nurse identify as priority?
- A. Sexual relations with her spouse
- B. Fetal growth and development
- C. Options for labor and delivery
- D. Preparing needed items for the baby
Correct Answer: B
Rationale: Information about fetal growth and development is priority and important to address during the first trimester, especially when the client expresses concerns about losing her baby. There is no indication that sexual relations are a concern for the client. Sexual relations, including intercourse, are safe during the first trimester. Labor and delivery options for the baby are priorities in the third trimester. The completion of preparations for the baby is a priority in the third trimester.
The pregnant client asks the nurse, who is teaching a prepared childbirth class, when she should expect to feel fetal movement. The nurse responds that fetal movement usually can first be felt during which time frame?
- A. 8 to 12 weeks of pregnancy
- B. 12 to 16 weeks of pregnancy
- C. 18 to 20 weeks of pregnancy
- D. 22 to 26 weeks of pregnancy
Correct Answer: C
Rationale: Subtle fetal movement (quickening) can be felt as early as 18 to 20 weeks of gestation, and it gradually increases in intensity. Eight to 12 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twelve to 16 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twenty-two to 26 weeks of pregnancy is later than expected to feel the first fetal movement.
The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/—1 and that the fetal HR is 148. What priority information should the nurse collect before proceeding?
- A. Time and amount of last meal
- B. Number of weeks’ gestation
- C. Who is attending the delivery
- D. History of previous illnesses
Correct Answer: B
Rationale: Knowing the weeks of gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. If she is full term, the labor process could continue. The time and amount of last meal is important to know, but number of weeks’ gestation is more important. This client is dilated at 4 cm and in active labor. Who will attend the delivery should be identified during admission to the labor unit, but it is not the most important when being evaluated in triage. History of previous illnesses should be collected during admission to the labor unit, but it is not the most important when being evaluated in triage.