Nokea
The nurse suspects that a client has an early sign of ectopic
- B. Abdominal pain
- C. Vaginal spotting or light bleeding
- D. Pelvic pain
Correct Answer: C
Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.
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Medication that are contraindicated for management of PPH include SATA (Cytotec, Hemabate, Pitocin, Methergine all for PPH)
- A. Terbutaline (for preterm labor)
- B. Magnesium sulfate
- C. Methergine
- D. Pitocin
Correct Answer: A
Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.
A patient who is older than 35 years may have difficulty achieving pregnancy because
- A. prepregnancy medical attention is lacking.
- B. personal risk behaviors influence fertility.
- C. contraceptives have been used for an extended period of time.
- D. the ovaries may be affected by the normal aging process.
Correct Answer: D
Rationale: As women age, their ovarian reserve decreases and the quality of their eggs declines, making it more difficult to conceive. This is due to the normal aging process of the ovaries, which can lead to decreased fertility and an increased risk of chromosomal abnormalities in the embryos. Therefore, a patient who is older than 35 years may have difficulty achieving pregnancy because the ovaries may be affected by the normal aging process.
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
- A. Place the client in the lateral position.
- B. Increase the rate of maintenance IV infusion.
- C. Elevate the client's legs.
Correct Answer: A
Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?
- A. Assess maternal vital signs and fetal heart rate.
- B. Prepare the client for immediate cesarean delivery.
- C. Administer oxygen at 2 L/min via nasal cannula.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Assessing maternal and fetal status is the first step to determine the urgency and appropriate intervention.