Nokea
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.
You may also like to solve these questions
The nurse is teaching a client about postpartum depression. What statement indicates understanding?
- A. It’s normal to feel hopeless for several weeks.
- B. Postpartum depression only occurs in first-time mothers.
- C. I should seek help if I feel disconnected from my baby.
- D. It is caused by a lack of support from family.
Correct Answer: C
Rationale: Feeling disconnected from the baby is a common symptom of postpartum depression and should prompt seeking help.
The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
- A. Uterine rigidity.
- B. Severe abdominal pain.
- C. Bright red vaginal bleeding.
- D. Soft, relaxed, nontender uterus.
Correct Answer: C
Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.
During which stage of the menstrual cycle does the endometrium layer thicken?
- A. Proliferative phase
- B. Ovulation phase
- C. Luteal phase
- D. Secretory phase
Correct Answer: D
Rationale: The endometrium layer thickens during the secretory phase of the menstrual cycle. This phase occurs after ovulation and is characterized by the endometrium preparing for possible implantation of a fertilized egg by further thickening and becoming more vascularized. If pregnancy does not occur, the thickened endometrial lining will be shed during menstruation. The secretory phase is under the control of the hormone progesterone, which is produced by the corpus luteum formed in the ovary after ovulation.
The nurse is preparing a client for a nonstress test. What instruction is most appropriate?
- A. You need to fast for 12 hours before the test.
- B. You will be given medication to stimulate fetal movements.
- C. You will need to press a button each time you feel the baby move.
- D. You must lie flat on your back during the test.
Correct Answer: C
Rationale: The client presses a button during fetal movements, which are correlated with fetal heart rate changes.
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
- A. Administer prescribed analgesic medication.
- B. Encourage the client to rest between contractions.
- C. Massage the client's back.
- D. Turn the client onto her left side.
Correct Answer: C
Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.