Nokea
The nurse is describing different types of abruptio placenta to a group of students explaining that the incomplete abruptio placenta is
- A. There is massive bleeding in the presence of almost total separation
- B. Separation beginning at the periphery of the placenta
- C. The placenta separates centrally and there can be concealed bleeding
- D. Blood passes between the fetal membrane of the uterine wall and is skipped vaginally
Correct Answer: B
Rationale: In incomplete abruptio placenta, the separation begins at the periphery of the placenta. This results in partial detachment of the placenta from the uterine wall, rather than almost total separation as seen in complete abruptio placenta. This type of abruptio placenta may present with vaginal bleeding depending on the extent of separation and may lead to various degrees of maternal and fetal compromise.
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The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Headaches B Nervousness
- B. Tremors
- C. Dyspnea
Correct Answer: C
Rationale: Terbutaline is a beta-adrenergic agonist that is commonly used to suppress preterm labor by relaxing the uterine smooth muscle. Adverse effects of terbutaline can include respiratory distress or dyspnea, which is a serious concern and should be reported to the healthcare provider immediately. Both the nurse and the client should be alert for signs of difficulty breathing, such as shortness of breath or chest tightness, as these symptoms could indicate a potential serious reaction to the medication. Headaches, nervousness, and tremors are common side effects of terbutaline that are less concerning and may not require immediate provider notification unless they become severe or persistent.
A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth?
- A. Pneumococcal
- B. Hepatitis
- C. Human papillomavirus
- D. Rubella
Correct Answer: D
Rationale: The CDC recommends that women who are not up-to-date with the MMR (measles, mumps, rubella) vaccine should receive it immediately postpartum. Rubella, also known as German measles, is particularly important during pregnancy because contracting rubella during pregnancy can lead to serious complications in the baby, such as birth defects and miscarriage. By ensuring the client receives the MMR vaccine postpartum, it helps protect both the mother and any future pregnancies from the risk of rubella infection.
A nurse is leading a discussion about contraception with a group of 14-year-old-client. After the presentation a client asks the client which method would be best for her to use. How should the nurse respond?
- A. "Because of your age, i think that a barrier method would be the best choice."
- B. "Before i can help you, i need to know more about your sexual activity."
- C. "A provider can help you with that after a physical examination."
- D. "You are so young. Are you ready for the responsibilities of a sexual relationship?"
Correct Answer: B
Rationale: The appropriate response for the nurse to provide to the 14-year-old client who asks the best contraception method for her is to gather more information about her sexual activity first. This approach is essential in understanding the client's individual needs and situation before recommending a suitable contraceptive method. It allows the nurse to offer personalized and accurate advice based on the client's specific circumstances, rather than making assumptions or providing generic recommendations. By starting with a discussion about the client's sexual activity, the nurse can ensure that the advice given is tailored to the client's needs and preferences, promoting informed decision-making and effective contraceptive use.
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include?
- A. "Your stomach will empty rapidly"
- B. "You should expect your uterus to double in size"
- C. "You should anticipate nasal stuffiness."
- D. "Your nipples will become lighter in color".
Correct Answer: B
Rationale: Option B, "You should expect your uterus to double in size," is the correct information to include when discussing expected changes during pregnancy at 24 weeks of gestation. By this time, the uterus has significantly expanded to accommodate the growing fetus, which is the most notable physical change during pregnancy. It is essential for the client to understand the normal physiological changes that occur during pregnancy to ensure they are informed and prepared for the expected progression of their pregnancy.