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111 terms

high risk ob nclex

A woman with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is:
Delivery of the fetus
What is the only known cure for preeclampsia?
Which clinical sign is not included in the classic symptoms of preeclampsia?
Absence of deep tendon reflexes
Which assessment finding would convince the nurse to "hold" the next dose of magnesium sulfate?
Abdominal palpation
Which intrapartal assessment should be avoided when caring for the woman with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome?
+3 edema
The nurse is explaining how to assess edema to the nursing students working on the antepartum unit. Which score indicates edema of lower extremities, face, hands, and sacral area?
Hydatidiform mole
A woman is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. What potential problem should be investigated?
Total placenta previa
Which maternal condition always necessitates delivery by cesarean section?
the pregnancy is less than 20 weeks.
Spontaneous termination of a pregnancy is considered to be an abortion if:
missed abortion.
An abortion in which the fetus dies but is retained in the uterus is called:
A placenta previa in which the placental edge just reaches the internal os is called:
Hard, boardlike abdomen
What condition would indicate concealed hemorrhage in an abruptio placentae?
assess fetal heart rate (FHR) and maternal vital signs.
The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode is to:
she should be assessed for signs of dehydration and starvation.
A 28-year-old primigravida is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on the knowledge that:
assess weight gain, location of edema, and urine for protein.
A 17-year-old primigravida has gained 4 lb since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to:
worsening disease and impending convulsion.
A client with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate:
fetus is Rh positive.
Rh incompatibility can occur if the woman is Rh negative and her:
Incomplete abortion at 10 weeks
In what situation would a dilation and curettage (D&C) be indicated?
Bed rest
What order should the nurse expect for a client admitted with a threatened abortion?
Recurrent pelvic infections
What data on a client's health history would place her at risk for an ectopic pregnancy?
Fundal height measurement of 18 cm
What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
Determining cervical dilation and effacement
What routine nursing assessment is contraindicated in the client admitted with suspected placenta previa?
presence of abdominal pain.
The primary symptom present in abruptio placentae that distinguishes it from placenta previa is:
decreased fibrinogen.
The nurse understands that a laboratory finding indicative of DIC is:
administer calcium gluconate.
A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should:
hemorrhage is the major concern.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that:
Degree of glycemic control before and during the pregnancy
Which factor is most important in diminishing maternal/fetal/neonatal complications in the pregnant woman with diabetes?
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
Previous birth of large infant
Which factor is known to increase the risk of gestational diabetes mellitus?
placental hormones are antagonistic to insulin, resulting in insulin resistance.
Glucose metabolism is profoundly affected during pregnancy because:
eating her meals and snacks on a fixed schedule.
To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant diabetic will need to alter her diet by:
eat 6 saltine crackers.
When the pregnant diabetic experiences hypoglycemia while hospitalized, the nurse should have the client:
varies depending on the stage of gestation.
Nursing intervention for the pregnant diabetic is based on the knowledge that the need for insulin:
Mitral valve prolapse
What form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
instruct her to avoid strenuous activity.
When teaching the pregnant woman with class II heart disease, the nurse should:
She must report any chest discomfort or productive cough.
Which instructions are most important to include in a teaching plan for a client in early pregnancy who has class I heart disease?
bacterial endocarditis.
Antiinfective prophylaxis is indicated for the pregnant woman with a history of mitral valve stenosis related to rheumatic heart disease because the woman is at risk of developing:
For which of the infectious diseases can a woman be immunized?
The woman must make arrangements to stay somewhere other than her home until the children are no longer contagious.
A woman who delivered her third child yesterday has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?
Plan for retesting during the third trimester.
A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action?
"Even though my test is positive, my baby might not be affected."
A woman has tested human immunodeficiency virus (HIV) positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
pelvic pain, abdominal pain, vaginal spotting or light bleeding, missed period.
Throughout the world the rate of ectopic pregnancy has increased dramatically over the past 20 years. This is believed to be due primarily to scarring of the fallopian tubes as a result of pelvic infection, inflammation, or surgery. The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for symptoms such as:
Which pelvic shape is most conducive to vaginal labor and delivery?
Keep underpads and linens as dry as possible
What actions of the nurse prevent infections in the labor and delivery area?
Cloudy amniotic fluid with strong odor
A pregnant woman with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicate a potential infection?
A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for at-home continuation of the tocolytic effect?
Lie supine and relax.
Which technique is least effective for the woman with persistent occiput posterior position?
cesarean delivery.
Birth for the nulliparous woman with a fetus in a breech presentation is usually by:
Methergine (an oxytocic drug) increases the blood pressure. The nurse should question the order to administer Methergine to the woman with a history of:
A multiparous woman at 39 weeks of gestation who is expecting twins
Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?
Incomplete uterine relaxation
Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?
palpate the infant's clavicles.
After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:palpate the infant's clavicles.
"I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."
A laboring client in the latent phase is experiencing uncoordinated, irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?
Dehydration stimulates secretion from the posterior pituitary.
Why is adequate hydration important when uterine activity occurs before pregnancy is at term?
Any activity could increase the risk of recurrence of labor contractions.
What activity guidelines should be included when teaching a client about home care for preterm labor?
Reposition the mother with her hips higher than her head.
Which nursing action must be initiated first when evidence of prolapsed cord is found?
notify the physician promptly.
A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action should be to:
Restore circulating blood volume by increasing the intravenous infusion rate.
What action should be initiated to limit hypovolemic shock when uterine inversion occurs?
Presenting part at a station of -3
What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord?
compression of the umbilical cord is more likely.
The fetus in a breech presentation is often born by cesarean delivery because:
encouraging urination about every 1 to 2 hours.
An important independent nursing action to promote normal progress in labor is:
"You should come into the office and let the doctor check you."
A woman who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is:
Fetal heart rate, maternal pulse, and blood pressure
"You should come into the office and let the doctor check you."
contractions abruptly stop during labor.
The nurse should suspect uterine rupture if:
false, This is often referred to as the "turtle sign" and is an indication of shoulder dystocia.
The nurse has been caring for a primiparous client who is suspected of carrying a macrosomic infant. Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle's head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary.
"I'll put my support stockings on every morning before rising."
Which statement by a postpartal woman indicates that further teaching is not needed regarding thrombus formation?
inspect the placenta after delivery.
The nurse knows that a measure for preventing late postpartum hemorrhage is to:
Postpartum blues
Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?
notify the physician.
A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should:
500 mL in the first 24 hours after vaginal delivery.
Early postpartum hemorrhage is defined as a blood loss greater than:
Assess the fundus for firmness.
A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action?
lacerations of the genital tract.
A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:
6.5-lb infant after a 2-hour labor.
A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a:
Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.
What instructions should be included in the discharge teaching plan to assist the client in recognizing early signs of complications?
oral methylergonovine maleate (Methergine) for 48 hours.
The nurse should expect medical intervention for subinvolution to include:
If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?
Local tenderness, heat, and swelling
The mother-baby nurse must be able to recognize what sign of thrombophlebitis?
Assist the client in performing leg exercises every 2 hours.
Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth?
100.8° F on the second and third postpartum days
Which temperature indicates the presence of postpartum infection?
possible infection.
A white blood cell (WBC) count of 28,000 cells/mm3 on the morning of the first postpartum day indicates:
facilitates drainage of lochia.
The client who is being treated for endometritis is placed in Fowler's position because it:facilitates drainage of lochia.
forcing fluids to at least 3000 mL/day.
Nursing measures that help prevent postpartum urinary tract infection include:
Initiating early and frequent feedings
Which measure may prevent mastitis in the breastfeeding mother?
the organisms that cause mastitis are not passed to the milk.
A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that:
odor of the lochia.
If the nurse suspects a uterine infection in the postpartum client, she should assess the:
The nurse is in the process of assessing the comfort level of her postpartum client. Excess bleeding is not obvious; however, the new mother complains of deep, severe pelvic pain. The registered nurse (RN) has noted both skin and vital sign changes. This client may have formed a ____________________.
False, On the contrary, the unusual activity of the hospital staff may make the mother and her family very anxious.
Should a postpartum complication such as hemorrhage occur, the nursing staff will spring into action to ensure that client safety needs are met. This level of activity is very reassuring to both the new mother and her family members as they can see that the client is receiving the best of care.
anemia, exhaustion, failure to attach to her infant, postpartum infection.
The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include:
Adequate prenatal care
What is most helpful in preventing premature birth?
greater surface area in proportion to weight.
In comparison with the term infant, the preterm infant has:
keeps the alveoli open during expiration.
Decreased surfactant production in the preterm lung is a problem because surfactant:
encourage the parents to touch her.
An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to:
it could make respiratory distress syndrome worse.
The most important reason to protect the preterm infant from cold stress is that:
is unable to coordinate sucking and swallowing.
The preterm infant who should receive gavage feedings instead of a bottle is the one who:
Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?
Lack of subcutaneous fat
What is a characteristic of the postterm infant who weighs 7 lb, 12 oz?
Retinopathy of prematurity (ROP)
In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?
blood glucose of 25 mg/dL.
In caring for the postterm infant, thermoregulation can be a concern, especially in the infant who also has a:
They are below the 10th percentile on gestational growth charts.
hich is true about newborns classified as small for gestational age (SGA)?
Prevent hypoglycemia by early and frequent feedings.
What nursing action is especially important for the SGA newborn?
The head seems large compared with the rest of the body.
What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction?
Three successive temperature measurements were 97° F, 96° F, and 97° F.
What data would alert the nurse caring for an SGA infant that additional calories may be needed?
They are prone to hypoglycemia, polycythemia, and birth injuries.
Which statement is true about large for gestational age (LGA) infants?
Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome?
hypoxia in utero.
While caring for the postterm infant, the nurse recognizes that the elevated hematocrit level most likely results from:
Cracked, peeling skin
What data would alert the nurse that the neonate is postmature?
Risk for infection
Because of the premature infant's decreased immune functioning, what nursing diagnosis would the nurse include in a plan of care for a premature infant?
put an undershirt on the infant in the incubator.
To maintain optimal thermoregulation for the premature infant, the nurse should:
nurture both the infant and the parents to optimize neonatal outcomes.
The neonatal intensive care unit (NICU) environment should:
problems with thermoregulation, hyperbilirubinemia, sepsis
Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for:
The NICU nurse begins her shift by assessing one of the preterm infants assigned to her care. The infant's color is pale, his O2 saturation has decreased, and he is grimacing. This infant is displaying common signs of ____________________.