Nokea
Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
- A. Urine output of 30 mL in 1 hour
- B. Blood pressure of 110/60 mm Hg
- C. Bleeding at IV insertion site
- D. Respiratory rate of 16 breaths per minute
Correct Answer: C
Rationale: The correct answer is C because bleeding at the IV insertion site could indicate disseminated intravascular coagulation (DIC), a major complication of placental abruption. DIC is a serious condition that results in widespread clotting and bleeding throughout the body. This finding signifies that the patient's clotting factors are being consumed rapidly, leading to uncontrolled bleeding. Options A, B, and D are not indicative of a major complication of placental abruption. A decreased urine output, low blood pressure, and normal respiratory rate may be seen in various conditions but are not specific to DIC or a major complication in this context.
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A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
- A. “I know I will need to have an abortion as soon as possible.”
- B. “Even though my test is positive, my baby might not be affected.”
- C. “My baby is certain to have AIDS and die within the first year of life.”
- D. “This pregnancy will probably decrease the chance that I will develop AIDS.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that a positive HIV test in the mother doesn't guarantee transmission to the baby. This reflects knowledge of the possibility of preventing mother-to-child transmission with proper medical care. Option A is incorrect as abortion is not the standard recommendation for HIV-positive pregnant women. Option C is incorrect as not all babies born to HIV-positive mothers will have AIDS or die within the first year. Option D is incorrect as pregnancy does not decrease the mother's chance of developing AIDS.
A patient at 32 weeks' gestation is diagnosed with polyhydramnios. The patient asks the nurse if polyhydramnios can affect the baby. What is the nurse's response to the patient's question?
- A. No, polyhydramnios commonly occurs toward the end of pregnancy.
- B. No, polyhydramnios is a sign that the lungs are maturing.
- C. Yes, polyhydramnios increases the risk of a preterm delivery.
- D. Yes, polyhydramnios causes umbilical cord compression.
Correct Answer: C
Rationale: The correct answer is C: Yes, polyhydramnios increases the risk of a preterm delivery. Polyhydramnios, an excess of amniotic fluid, can lead to uterine overdistension, which may trigger premature labor. The increased pressure from the excess fluid can also cause premature rupture of membranes. This complication can potentially result in a preterm delivery, which carries risks for the baby's health and development. Choices A and B are incorrect because polyhydramnios is not a normal occurrence at the end of pregnancy nor a sign of lung maturity. Choice D is incorrect as umbilical cord compression is a potential complication of polyhydramnios but not the primary risk associated with it.
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. In HELLP syndrome, there is hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia, a key feature of HELLP syndrome. It signifies ongoing coagulation abnormalities and liver dysfunction.
B: Liver enzyme levels within normal range is incorrect as HELLP syndrome typically presents with elevated liver enzymes.
C: Negative for edema is incorrect as edema is not a defining characteristic of HELLP syndrome.
D: No evidence of nausea or vomiting is incorrect as these symptoms are not specific to HELLP syndrome.
A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication, which action should the nurse take?
- A. Increase the patient's IV fluids.
- B. Administer calcium gluconate.
- C. Vigorously stimulate the patient.
- D. Instruct the patient to take deep breaths.
Correct Answer: B
Rationale: The correct answer is B: Administer calcium gluconate. This is because magnesium sulfate can lead to respiratory depression by inhibiting neuromuscular transmission. Calcium gluconate is the antidote as it competes with magnesium for binding sites, reversing its effects. Increasing IV fluids (A) is not directly related to addressing respiratory depression. Vigorously stimulating the patient (C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (D) may not be effective in addressing respiratory depression caused by magnesium sulfate.
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
- A. Female fetus, Mexican-American, primigravida
- B. Male fetus, Asian-American, previous preterm birth
- C. Male fetus, African-American, previous cesarean birth
- D. Female fetus, European-American, previous spontaneous abortion
Correct Answer: C
Rationale: The correct answer is C: Male fetus, African-American, previous cesarean birth. Placenta previa occurs when the placenta partially or completely covers the cervix. African-American women have a higher incidence of placenta previa. Previous cesarean birth is a risk factor due to possible scarring on the uterine wall, increasing the likelihood of placenta implantation issues. Male fetuses are associated with a higher risk of placenta previa, possibly due to a larger placental size. The other choices do not align with known risk factors for placenta previa, such as the ethnicity, fetal gender, and obstetric history mentioned.