PQs for Complicated

Which nursing intervention and rationale applies to a client who has just given birth to a fifth child?

A) Palpating the fundus frequently, because this client is at increased risk for uterine atony

B) Offering fluids, because multiparas generally lose more fluid during labor

C) Assessing bladder tone, because there is increased risk for urinary tract infection

D) Performing passive range-of-motion exercises on the extremities, because there is a risk for thrombophlebitis

A

A client’s membranes ruptured 20 hours before admission. She gave birth 18 hours after admission. For which postpartum complication is this client at risk?

A) Infection

B) Hemorrhage

C) Uterine atony

D) Amniotic fluid embolism

A

A sonogram performed on a client in the third trimester reveals a low-lying placenta. Which would the nurse teach the client that she is at risk for?

A) Sharp abdominal pain

B) Painless vaginal bleeding

C) Increased lower back pain

D) Early rupture of membrane

B

Which is the most therapeutic instruction for the nurse to provide to a client with severe preeclampsia?

A) "Eat a sodium-restricted diet."

B) "Walk at least 1 mile (2.2 km) every day."

C) "Rest often in the side-lying position."

D) "Limit fluid intake to 1000 mL daily."

C

Which is the nurse’s priority action when caring for an obstetrical client experiencing eclampsia?

A) Turn the head to one side.

B) Obtain the fetal heart rate.

C) Administer intravenous analgesia.

D) Place an oral airway.

A

A gravida 1 client with B negative blood gives birth to a baby whose blood type is O positive. Which intervention would the nurse expect to be included in the client’s plan of care?

A) Administration of Rho (D) immune globulin

B) Determination of the father’s blood type

C) Check for signs of ABO incompatibility

D) Blood typing and cross-matching

A

Which action would the nurse implement to enhance safety for a laboring client and fetus with a prolapsed cord? Select all that apply.  One, some, or all responses may be correct.

A) Quickly gloving the examining hand and inserting two fingers into the vagina to the cervix

B) Immediately notifying the client’s primary health care provider

C) Administering oxygen to the client via a nonrebreather mask

D) Placing the client in the extreme Trendelenburg position

E) Increasing the client’s intravenous fluid drip rate

ABCDE

During the first hour after a cesarean birth, the nurse notes that the client’s lochia has saturated one perineal pad. Which clinical judgment would the nurse make based on this finding?

A) Scant lochial flow

B) Postpartum hemorrhage

C) Retained placental fragments

D) Lochial flow within expected limits

D

An electronic fetal monitor is applied to a client in labor who is dilated to 4 cm. Which assessment finding would cause the nurse to notify the health care provider?

A) Contractions every 4 minutes that last 50 seconds

B) Contractions every 1 to 2 minutes lasting 90 seconds

C) Fetal heart rate accelerations at the beginning of a contraction

D) Fetal heart rate decelerations to 110 beats/min before the peak of a contraction

B

Which action would the nurse take first for a client who is in active labor and experiences sudden vaginal bleeding and increased uterine tone without relaxation between contractions?

A) Transport the client for a cesarean birth.

B) Check the perineum for rupture of membranes.

C) Change the underpad and position the client on her left side.

D) Assess the fetal heart rate, uterine activity, and blood pressure.

D

Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. Which action would the nurse take in response to these findings?

A) Stop the infusion of magnesium sulfate and notify the primary health care provider.

B) Administer calcium gluconate, because it is an antidote to magnesium sulfate.

C) Continue the magnesium sulfate infusion, because the blood pressure is still high.

D) Check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary.

B

Which orders are appropriate for a client with mild preeclampsia? Select all that apply. One, some, or all responses may be correct.

A) Glucose tolerance test

B) Monitor deep tendon reflexes

C) 2 g/day sodium diet

D) Side-lying bed rest

E) Daily weight

BE

Which nursing action is the priority action for a breastfeeding postpartum client receiving an infusion of magnesium sulfate during the immediate postpartum period?

A) Monitoring oral intake

B) Monitoring urinary output

C) Observing amount of lochia

D) Assessing breast-feeding technique

C

Which nursing interventions are applicable to a client receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. One, some, or all responses may be correct.

A) Keeping calcium gluconate at the bedside

B) Maintaining a quiet environment

C) Preparing for a precipitate birth

D) Limiting fluid intake

E) Restricting visitors

ABDE

A client in early active labor at 40 weeks’ gestation reports that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. Which is the priority nursing action?

A) Assessing maternal vital signs

B) Planning for an emergency birth

C) Administering oxygen by way of nasal cannula

D) Preparing for fetal scalp blood sampling

A

For which reason is a client with heavy bleeding from a complete placenta previa placed in a lateral Trendelenburg position?

A) To prevent shock

B) To control bleeding

C) To keep pressure off the cervix

D) To move the placenta off the cervix

A

A recently postpartum client who has heavy vaginal bleeding that does not lessen after fundal massage says, "I’m so thirsty. May I have some ginger ale?" Which is an appropriate reply by the nurse?

A) "It’s good to replenish your fluids. I’ll bring you some ginger ale right away."

B) "You want to drink to balance out the blood loss, but carbonated fluids are not a good choice."

C) "I can imagine how thirsty you are, but I need to get clearance from the primary health care provider before I can give you anything to drink."

D) "I know this is difficult; however, it’s best for you to wait until the bleeding has subsided. I can give you a moisturizer for your lips to relieve the dryness."

D

Which baseline assessment data would the nurse obtain on a client with preeclampsia before initiation of a magnesium sulfate infusion? Select all that apply. One, some, or all responses may be correct.

A) Urine specific gravity

B) Blood pressure

C) Respiratory rate

D) Urine output

E) Patellar reflex

BCDE

A woman is being seen in the prenatal clinic at 36 weeks’ gestation. Which signs and symptoms by the client require further evaluation by the primary health care provider? Select all that apply. One, some, or all responses may be correct.

A) Shortness of breath after climbing a flight of stairs

B) Contractions that are regular and 5 minutes apart

C) Heartburn after eating a fatty meal

D) Urinary frequency without dysuria

E) Blurred vision with spots

F) Decreased urine output

BEF

Which statement from a pregnant client with premature rupture of membranes (PROM) demonstrates an understanding of the infection risk? Select all that apply.  One, some, or all responses may be correct.

A) "I will let my doctor know if I experience foul-smelling vaginal discharge."

B) "If I develop chorioamnionitis, my doctor will induce labor."

C) "If I have contractions, medications will be administered."

D) "I will wipe from front to back when using the bathroom."

E) "I will report a fever to my doctor."

ABCDE

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. Which action would the nurse’s plan of care include?

A) Withholding oral fluid intake

B) Discussing the need for formula feeding

C) Obtaining permission for a paracervical block

D) Applying moist compresses to the perineal area

A

Which is the priority nursing action when a loop of umbilical cord protrudes from the vagina after rupture of a client’s membranes?

A) Monitoring the fetal heart rate

B) Covering the cord with a saline dressing

C) Checking intensity and duration of contractions

D) Holding the presenting part away from the cord

D

Which activity would the nurse suggest for a client in labor who is having frequent painful contractions and whose cervix has been dilated 2 cm for several hours without progression?

A) Lying in bed on the right side

B) Therapeutic rest

C) Taking a walk around the labor unit

D) Using nipple stimulation to augment labor

B

A client with mild preeclampsia is admitted to the labor and birthing suite. Which signs or symptoms would the client be likely to display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. One, some, or all responses may be correct.

A) Nausea and vomiting

B) Vaginal bleeding

C) Right upper quadrant abdominal pain

D) Constipation

E) Headache

ACE