Nokea
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?
- A. Saturated perineal pad in 1 hour
- B. Pain level 0 on a scale of 0 to 10
- C. Cervical dilation at 2 cm
- D. Fetal heart rate at 160 bpm
Correct Answer: B
Rationale: The correct answer is B because in placenta previa, pain is usually minimal or absent, while in abruptio placentae, there is severe abdominal pain. Saturated perineal pad (choice A) is common in both conditions. Cervical dilation (choice C) is not specific to differentiate between the two conditions. Fetal heart rate (choice D) may be normal in both conditions.
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Which position increases cardiac output in the obstetrical client with cardiac disease?
- A. Trendelenburg
- B. Low semi-Fowler
- C. Lateral positioning
- D. Supine with legs elevated
Correct Answer: C
Rationale: The correct answer is C: Lateral positioning. This position increases cardiac output in obstetrical clients with cardiac disease by improving venous return to the heart, reducing pressure on the vena cava, and optimizing uteroplacental perfusion. The other choices are incorrect because Trendelenburg can worsen cardiac function by increasing venous return and intracardiac volume, low semi-Fowler does not optimize venous return and may decrease preload, and supine positioning with legs elevated can compress the vena cava, leading to decreased cardiac output and potential hypotension.
A placenta previa when the placental edge just reaches the internal os is called
- A. total.
- B. partial.
- C. low-lying.
- D. marginal.
Correct Answer: D
Rationale: The correct answer is D: marginal. In placenta previa, when the placental edge just reaches the internal os, it is classified as marginal. This indicates that the placenta is close to, but not covering, the cervical os. Total previa covers the entire os, partial covers part of it, and low-lying indicates the placental edge is near the os but not reaching it. The key is to understand the specific location of the placental edge in relation to the internal os for each classification.
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action?
- A. Administering oxygen
- B. Elevating the head of the bed
- C. Drawing blood for a hematocrit level
- D. Giving an intramuscular analgesic
Correct Answer: A
Rationale: The correct immediate nursing action is to administer oxygen (Choice A) to ensure adequate oxygenation for both the mother and the fetus. Oxygen is crucial in cases of vaginal bleeding as it helps maintain tissue perfusion and prevent hypoxia. Elevating the head of the bed (Choice B) is not the priority as oxygenation should be addressed first. Drawing blood for a hematocrit level (Choice C) may provide valuable information but does not address the immediate need for oxygen. Giving an intramuscular analgesic (Choice D) is not appropriate without knowing the cause of the pain and bleeding.
A patient at 10 weeks' gestation informs the nurse they are having vaginal bleeding and cramping. After completing a speculum examination, the health-care provider (HCP) informs the patient their cervix is open. What does the nurse anticipate the HCP will inform the patient they are experiencing?
- A. complete abortion
- B. incomplete abortion
- C. inevitable abortion
- D. spontaneous abortion
Correct Answer: C
Rationale: The correct answer is C: inevitable abortion. At 10 weeks' gestation, an open cervix with vaginal bleeding and cramping indicates an inevitable abortion, where the miscarriage is unavoidable and the process is ongoing. The open cervix suggests that the pregnancy is not viable and will not continue. The other options are incorrect because: A. Complete abortion refers to the expulsion of all products of conception, B. Incomplete abortion involves partial expulsion of products of conception, and D. Spontaneous abortion is a general term for any non-induced abortion.
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
- A. immediate birth is required.
- B. the patient should be transferred to the critical care unit for closer observation.
- C. RhoGAM should be administered.
- D. a tetanus shot should be administered.
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The positive Kleihauer–Betke test indicates fetal-maternal hemorrhage, where fetal blood enters the maternal circulation. This can lead to fetal-maternal transfusion, causing fetal anemia. Immediate birth is necessary to assess and manage potential fetal distress, such as anemia and hypoxia, due to the trauma from the MVA.
Choices B, C, and D are incorrect:
B: Transferring to critical care unit is not the immediate priority. The focus should be on addressing the fetal distress.
C: RhoGAM is given to Rh-negative mothers to prevent Rh sensitization, but it is not directly related to the positive Kleihauer–Betke test result.
D: Tetanus shot administration is important for tetanus prevention, but it is not the priority in this case where immediate birth is required due to fetal-maternal hemorrhage.