Nokea
Which data support a diagnosis of abruptio placenta in a pregnant woman?
- A. Uterine rigidity and abdominal pain
- B. Painless bleeding with soft abdomen
- C. Premature rupture of membranes and uterine contractions
- D. Bright red blood loss and elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Uterine rigidity and abdominal pain. Abruptio placenta is characterized by premature separation of the placenta from the uterine wall. Uterine rigidity indicates the presence of a hypertonic uterus due to the sudden hemorrhage, leading to severe abdominal pain. This is a classic presentation of abruptio placenta. Choices B, C, and D do not align with the typical clinical features of abruptio placenta. Painless bleeding with a soft abdomen does not suggest an acute and painful condition like abruptio placenta. Premature rupture of membranes and uterine contractions are more indicative of preterm labor or premature rupture of membranes, not abruptio placenta. Bright red blood loss and elevated blood pressure are more characteristic of placenta previa or preeclampsia, respectively, not abruptio placenta.
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For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?
- A. Hemoglobin 10.2 mg/dL and uterine tenderness
- B. Polyuria and weight loss of 3 pounds in the last month
- C. Blood pressure 168/110 and 3+ proteinuria
- D. Hematuria and blood glucose of 160 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 168/110 and 3+ proteinuria. Pregnancy-induced hypertension (PIH) is characterized by high blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg) and proteinuria. In this case, the blood pressure reading of 168/110 indicates hypertension, and 3+ proteinuria indicates significant protein in the urine, both of which are key diagnostic criteria for PIH.
A: Hemoglobin 10.2 mg/dL and uterine tenderness - These are not specific indicators of PIH.
B: Polyuria and weight loss of 3 pounds in the last month - These symptoms are not typically associated with PIH.
D: Hematuria and blood glucose of 160 mg/dL - Hematuria suggests blood in the urine, which is not a typical finding in PIH, and elevated blood glucose is more indicative of diabetes rather than PIH.
Therefore,
During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate?
- A. Hold the presenting part away from the cord
- B. Insert a scalp electrode for an internal fetal monitor
- C. Place the client in reverse Trendelenburg position
- D. Cover the cord with a dry,sterile gauze
Correct Answer: A
Rationale: The correct answer is A: Hold the presenting part away from the cord. This action helps relieve pressure on the cord, preventing further compromise of blood flow to the fetus. It is crucial to maintain fetal perfusion. Choice B (Insert a scalp electrode) and D (Cover the cord with gauze) are not appropriate as they do not address the immediate risk of cord compression. Choice C (Reverse Trendelenburg) may worsen the prolapse by shifting the presenting part higher.
A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?
- A. Contractions that are irregular and decrease in intensity when walking
- B. Abdominal pain that starts at the fundus and progresses to the lower back
- C. Increased pressure on the bladder and urinary frequency
- D. Expulsion of pink-tinged mucous and contractions that start in the lower back
Correct Answer: D
Rationale: The correct answer is D because the expulsion of pink-tinged mucous (bloody show) and contractions starting in the lower back are indicative of true labor. This is due to the release of the mucus plug and the initiation of true uterine contractions. Contractions that start in the lower back and progress to the front are characteristic of true labor.
Choice A is incorrect because contractions that are irregular and decrease in intensity with walking are characteristic of false labor (Braxton Hicks contractions).
Choice B is incorrect as abdominal pain starting at the fundus and progressing to the lower back is not a specific sign of true labor.
Choice C is incorrect as increased pressure on the bladder and urinary frequency are common throughout pregnancy and not specific to the onset of true labor.
In summary, the correct answer D provides specific and characteristic signs of true labor, while the other choices do not accurately reflect the onset of true labor.
A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering?
- A. Tocolytics
- B. Anticonvulsants
- C. Glucocorticoids
- D. Anti-infective
Correct Answer: A
Rationale: The correct answer is A: Tocolytics. Tocolytics are drugs used to inhibit uterine contractions and delay preterm labor. They help prevent premature birth and allow time for other interventions. Anticonvulsants (B) are used to treat seizures, not preterm labor. Glucocorticoids (C) are given to enhance fetal lung maturity in preterm labor, but do not inhibit contractions. Anti-infectives (D) are used to treat infections, not preterm labor. Therefore, tocolytics are the most appropriate choice in this scenario.
A nurse is caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI). The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of the following statements made by the parent indicates a correct understanding of the manifestations of a UTI?
- A. I should look for more frequent urination and strong-smelling urine.
- B. My child would have tea-colored urine and puffiness around the eyes.
- C. I should observe for episodes of nausea and less frequent urination.
- D. My child would have pale-colored urine and abdominal tenderness and pain.
Correct Answer: A
Rationale: Frequent urination and strong-smelling urine are classic signs of a UTI.