Question

A nurse is caring for a client who is at 28 weeks of gestation.

Answer 1

Correct Answers

Blank 1 Correct Option: Placenta previa
Blank 2 Correct Option: Insert a large-bore peripheral IV catheter and Instruct the client to maintain bed rest.
Blank 3 Correct Option: Fetal well-being and Vaginal bleeding

Rationale :

Condition:

Placenta previa

🩸 Placenta previa occurs when the placenta implants in the lower uterine segment and partially or completely overlies the cervical opening, creating a high risk for painless vaginal bleeding as the cervix and lower uterus change during pregnancy.

🩸 The client's sudden, painless, bright-red vaginal bleeding, absence of contractions, and soft, nontender abdomen are classic findings associated with placenta previa.

🩸 The client's hypotension of 86/48 mm Hg, tachycardia of 120/min, hemoglobin of 9 g/dL, and hematocrit of 25% indicate significant maternal blood loss and evolving hypovolemia.

🩸 The fetal heart rate of 170/min with minimal variability suggests the fetus may already be experiencing compromised oxygenation secondary to reduced maternal circulating blood volume.

🩸 Placenta previa therefore best explains the clinical presentation and requires immediate interventions aimed at stabilizing maternal circulation, limiting further bleeding, and protecting fetal well-being.

Actions

Insert a large-bore peripheral IV catheter

🩸A large-bore peripheral IV catheter should be inserted immediately because the client is showing evidence of significant hemorrhage and hemodynamic compromise.

🩸 Large-bore access allows rapid administration of isotonic IV fluids, blood products, and emergency medications if the client's condition worsens.

🩸The client's blood pressure of 86/48 mm Hg and heart rate of 120/min indicate reduced circulating volume and possible hypovolemic shock.

🩸Type and cross-match testing has already been initiated, which further supports preparation for possible blood transfusion if bleeding continues or laboratory values decline.

🩸Establishing reliable vascular access is therefore a priority intervention to restore maternal perfusion and fetal oxygen delivery.

Instruct the client to maintain bed rest

🩸Bed rest limits physical activity and pelvic pressure, which may help reduce further disruption of placental vessels in placenta previa.

🩸The client should avoid unnecessary ambulation because continued bleeding combined with existing hypotension places her at risk for syncope, worsening hemorrhage, and fetal compromise.

🩸 Pelvic rest is also essential, meaning the client should avoid sexual intercourse and any unnecessary vaginal manipulation.

🩸Maintaining a controlled resting position allows the healthcare team to continuously evaluate maternal vital signs, fetal status, and ongoing blood loss.

🩸Bed rest therefore supports stabilization while definitive management is determined based on bleeding severity, gestational age, and maternal-fetal condition.

Parameters

Fetal well-being

🩸Continuous assessment of fetal well-being is essential because maternal blood loss can decrease uteroplacental perfusion and fetal oxygen delivery.

🩸The current fetal heart rate of 170/min with minimal variability is already concerning for possible fetal stress or reduced oxygenation.

🩸Electronic fetal monitoring allows the nurse to detect persistent tachycardia, decreasing variability, bradycardia, or decelerations that may indicate worsening compromise.

🩸Changes in the fetal heart rate pattern can provide an early indication that maternal hemorrhage is affecting the fetus before other clinical signs become obvious.

🩸Ongoing fetal assessment therefore helps determine whether continued observation is safe or whether urgent obstetric intervention and possible delivery are required.

Vaginal bleeding

🩸 The nurse should closely monitor vaginal bleeding because continued hemorrhage can rapidly worsen maternal hypovolemia and fetal compromise.

🩸 Perineal pads should be assessed and, when possible, weighed because 1 gram of increased pad weight is approximately equivalent to 1 mL of blood loss.

🩸 Increasing bright-red bleeding, passage of clots, or blood pooling beneath the client would indicate ongoing or worsening placental hemorrhage.

🩸 Bleeding trends should be interpreted together with heart rate, blood pressure, hemoglobin, hematocrit, mental status, and urine output to assess maternal perfusion.

🩸 Accurate monitoring of blood loss is essential for determining the need for fluid resuscitation, blood transfusion, and emergency delivery.

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Answer 2

Correct Answers:

Hct
Vaginal bleeding
Fetal heart rate

Rationale :

Vaginal bleeding

🩸 The client's moderate amount of bright-red vaginal bleeding requires immediate follow-up because active hemorrhage is a major complication of complete placenta previa.

🩸 Placenta previa classically causes sudden, painless, bright-red vaginal bleeding because placental vessels can tear as the lower uterine segment stretches.

🩸 The client's report of a sudden “gush” of blood indicates that bleeding is active and could increase rapidly despite her currently stable blood pressure.

🩸 Continued hemorrhage can cause maternal hypovolemia, decreased uteroplacental perfusion, fetal hypoxia, and hemorrhagic shock if not promptly managed.

🩸 The nurse should therefore immediately quantify blood loss, monitor maternal hemodynamic status, maintain IV access, and continue continuous fetal monitoring.

Hematocrit 27%

🩸 The client's hematocrit of 27% is below the expected value of greater than 33%, indicating a decreased proportion of circulating red blood cells.

🩸 A low hematocrit is particularly concerning in a client with active vaginal hemorrhage because it supports the presence of clinically significant blood loss and anemia.

🩸 Continued bleeding can reduce the hematocrit further and impair the client's ability to maintain adequate oxygen delivery to maternal tissues and the placenta.

🩸 Serial hematocrit measurements are important for determining whether blood loss is progressing and whether the client might require blood-product replacement.

🩸 The combination of a 27% hematocrit and ongoing bright-red bleeding therefore requires prompt assessment and intervention.

Fetal heart rate 174/min

🩸 A fetal heart rate of 174/min is fetal tachycardia, because the expected baseline fetal heart rate is approximately 110 to 160/min.

🩸 Maternal hemorrhage can decrease circulating blood volume and uteroplacental perfusion, reducing the amount of oxygen delivered to the fetus.

🩸 Fetal tachycardia can represent an early sign of fetal stress or compromised oxygenation, especially when it occurs during active maternal bleeding.

🩸 Continuous electronic fetal monitoring is necessary to identify additional concerning changes such as minimal variability, recurrent decelerations, or eventual bradycardia.

🩸 The fetal heart rate therefore requires immediate follow-up because persistent tachycardia may signal that the fetus is being adversely affected by the maternal hemorrhage.

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Answer 3

Correct Answers

Blank 1 Correct Option: Rho(D) immune globulin
Blank 2 Correct Option: client’s blood type

Rationale :

🩸 Rho(D) immune globulin is indicated for an Rh-negative, unsensitized mother who may have been exposed to Rh-positive fetal blood during pregnancy or birth.

🩸 This client has a blood type of O positive (O+), which means she is Rh-positive and therefore does not require Rho(D) immune globulin for prevention of Rh sensitization.

🩸 Rho(D) immune globulin works by preventing an Rh-negative mother from developing antibodies against Rh-positive fetal erythrocytes, protecting future pregnancies from hemolytic disease of the fetus and newborn.

🩸 Administration to an Rh-positive client provides no therapeutic benefit, so the nurse should withhold the medication and clarify the prescription with the healthcare provider.

🩸 The client's positive Rh status is the key finding that makes this medication prescription inappropriate.

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Answer 4

Correct Answers:

Pad the side rails of the client's bed.

Rationale :

🧠 Padding the side rails is the priority seizure precaution because a client with preeclampsia is at risk for developing eclampsia and generalized tonic-clonic seizures.

🧠 During a seizure, uncontrolled muscle activity can cause the client to strike the bed rails and sustain significant head or extremity injuries.

🧠 Padded rails provide immediate environmental protection while keeping the client safely contained in the bed.

🧠 Additional precautions include maintaining the bed in a low position, reducing environmental stimulation, and keeping oxygen and suction equipment available.

🧠 Preventing traumatic injury is therefore the priority when establishing seizure precautions for a client with preeclampsia.

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Answer 5

Correct Answers:

Obtain an imprint of the infant's feet prior to taking him to the nursery.

Rationale :

👶 Obtaining the newborn's footprints soon after birth provides an additional means of identification before the newborn leaves the birth area.

👶 Footprints are traditionally documented together with maternal information and other newborn identification data as part of the facility's security procedures.

👶 Identification bands should also be applied to the newborn and parent according to institutional policy before separation occurs.

👶 Proper newborn identification reduces the risk of infant misidentification, incorrect procedures, and discharge to the wrong family.

👶 The footprint should therefore be obtained before transporting the newborn to the nursery as part of the initial identification process.

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Answer 6

Correct Answers:

Administer broad-spectrum antibiotics.

Rationale :

🧠 A leaking myelomeningocele exposes neural tissue and cerebrospinal fluid, creating a significant risk for meningitis and systemic infection.

🧠 Broad-spectrum antibiotics may be prescribed prophylactically because microorganisms can enter through the open spinal defect.

🧠 The lesion should also be covered with a sterile, moist, nonadherent dressing to prevent drying and further contamination.

🧠 The newborn is usually positioned prone to prevent pressure, trauma, and rupture of the exposed sac.

🧠 Prompt infection prevention and early surgical management are essential for protecting the exposed neural structures and preventing potentially life-threatening complications.

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Answer 7

Correct Answers:

An urge to have a bowel movement during contractions

Rationale :

🤰 An urge to have a bowel movement during contractions can indicate that the fetal head is exerting pressure on the rectum and pelvic floor.

🤰 This sensation frequently occurs as the cervix approaches complete dilation and the client enters the second stage of labor.

🤰 The nurse should promptly reassess cervical dilation and fetal descent before allowing the client to ambulate to the bathroom.

🤰 Failure to recognize this finding could result in an unexpected or unattended birth, particularly in a multiparous client whose labor may progress rapidly.

🤰 The sensation therefore warrants immediate reassessment to determine whether the client is ready to begin pushing.

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Answer 8

Correct Answers:

"This test will detect the presence of Rh-positive antibodies in your blood."

Rationale :

🩸 The indirect Coombs test screens maternal serum for antibodies directed against red blood cell antigens that could cross the placenta.

🩸 In an Rh-negative client, the test is particularly important for detecting anti-D antibodies that may develop following exposure to Rh-positive fetal blood.

🩸 These maternal antibodies can cross the placenta and destroy fetal erythrocytes, causing hemolytic disease of the fetus and newborn.

🩸 A negative result indicates that clinically significant maternal antibodies have not been detected, while a positive result requires additional evaluation and monitoring.

🩸 The test therefore helps determine whether maternal alloimmunization poses a risk to the fetus.

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Answer 9

Correct Answers:

Persistent headaches

Rationale :

💊 Persistent or severe headaches in a client taking an oral contraceptive can indicate a serious vascular complication and require immediate evaluation.

💊 Estrogen-containing contraceptives increase the risk of thromboembolic events, including ischemic stroke, especially in clients with additional risk factors.

💊 A new severe headache or migraine with neurologic manifestations may represent cerebral vascular compromise rather than a minor medication effect.

💊 The client should be instructed to report persistent headaches promptly, particularly when accompanied by visual disturbances, weakness, numbness, or speech changes.

💊 Recognizing this ACHES warning sign supports early identification of potentially life-threatening complications associated with hormonal contraception.

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Answer 10

Correct Answers:

Heart palpitations.

Rationale :

💓 Heart palpitations are a recognized adverse effect of terbutaline because beta-adrenergic stimulation can increase maternal heart rate and cardiac activity.

💓 Although terbutaline primarily stimulates beta₂ receptors to relax uterine smooth muscle, some beta₁ activity can produce tachycardia, tremors, and palpitations.

💓 Maternal pulse should be monitored carefully because excessive tachycardia can indicate significant cardiovascular stimulation.

💓 Terbutaline may need to be withheld and the provider notified when maternal tachycardia becomes significant according to the prescribed parameters and clinical condition.

💓 Monitoring cardiovascular status is therefore essential during terbutaline therapy for preterm uterine contractions.

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QLexNursing

1 :
A nurse is caring for a client who is at 28 weeks of gestation.

Correct Answers

2 :
A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa.

Answer Options

3 :
A nurse is preparing to administer medications to a client who is 72hr postpartum following a caesarean birth.

Correct Answers

4 :
A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?

5 :
A nurse manager is revising a maternal unit policy to ensure proper identification of new-borns. Which of the following should the nurse include in the policy?

6 :
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

7 :
A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

8 :
A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

9 :
A nurse is caring for a client who is taking an oral contraceptive. The nurse should instruct the client to report which of the following findings to the provider immediately?

10 :
A nurse is caring for a client who is receiving terbutaline to treat preterm labour. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

QLexNursing

1 : A nurse is caring for a client who is at 28 weeks of gestation.

Correct Answers

2 : A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa.

Answer Options

3 : A nurse is preparing to administer medications to a client who is 72hr postpartum following a caesarean birth.

Correct Answers

4 : A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?

5 : A nurse manager is revising a maternal unit policy to ensure proper identification of new-borns. Which of the following should the nurse include in the policy?

6 : A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

7 : A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

8 : A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

9 : A nurse is caring for a client who is taking an oral contraceptive. The nurse should instruct the client to report which of the following findings to the provider immediately?

10 : A nurse is caring for a client who is receiving terbutaline to treat preterm labour. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

1 :
A nurse is caring for a client who is at 28 weeks of gestation.

2 :
A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa.

3 :
A nurse is preparing to administer medications to a client who is 72hr postpartum following a caesarean birth.

4 :
A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?

5 :
A nurse manager is revising a maternal unit policy to ensure proper identification of new-borns. Which of the following should the nurse include in the policy?

6 :
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

7 :
A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

8 :
A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

9 :
A nurse is caring for a client who is taking an oral contraceptive. The nurse should instruct the client to report which of the following findings to the provider immediately?

10 :
A nurse is caring for a client who is receiving terbutaline to treat preterm labour. Which of the following findings should the nurse identify as a potential adverse effect of this medication?