Question

A nurse is caring for a client who is in labor and experiences abruptio placenta. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Uterine tenderness.

Rationale :

🌸 Abruptio placentae causes bleeding between the placenta and uterine wall, leading to painful uterine tenderness and a firm abdomen.

🌸 The tenderness results from blood accumulation and separation, making it a hallmark symptom distinct from painless bleeding of placenta previa.

🌸 Early identification of uterine tenderness helps prevent complications like fetal hypoxia or maternal hemorrhage.

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Answer 2

Correct Answers:

Tetanus.

Rationale :

🎯 Tetanus vaccination is safe during pregnancy and prevents maternal and neonatal tetanus infections, especially critical after 20 weeks.

🎯 Rubella and varicella vaccines are live and contraindicated during pregnancy because they pose a risk of fetal infection.

🎯 Tetanus protection is standard prenatal care to ensure both maternal immunity and passive immunity for the newborn.

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Answer 3

Correct Answers:

Facial asymmetry.

Rationale :

🎭 Forceps-assisted deliveries can cause trauma to the facial nerve, resulting in temporary or permanent facial asymmetry in the newborn.

🎭 Newborns with this injury often show uneven movements when crying, but usually recover fully within a few weeks.

🎭 Monitoring and documenting asymmetrical facial expressions are essential for early intervention if nerve damage is suspected.

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Answer 4

Correct Answers:

Persistent headaches.

Rationale :

🧠 Persistent headaches while on oral contraceptives may indicate hypertension or increased risk for thromboembolic events, both serious complications.

🧠 Estrogen in contraceptives can cause vascular changes, leading to severe migraines or signs of stroke risk.

🧠 Immediate provider notification ensures early assessment and prevention of critical events like stroke or DVT.

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Answer 5

Correct Answers:

Blood pressure 88/40 mm HO.

Rationale :

💔 A low blood pressure postpartum, especially after delivering a macrosomic infant, indicates potential postpartum hemorrhage, a life-threatening emergency.

💔 Early signs of hemorrhage include hypotension, tachycardia, and decreased urinary output, requiring urgent intervention.

💔 Recognizing vital sign changes quickly is critical for preventing severe hypovolemia and shock in postpartum clients.

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Answer 6

Correct Answers:

An urge to have a bowel movement during contractions.

Rationale :

🚽 An urge to defecate during labor often indicates fetal descent into the birth canal, signaling that the second stage of labor is imminent.

🚽 This sensation results from pressure exerted by the fetal presenting part on the rectum and pelvic floor nerves.

🚽 Immediate reassessment, including cervical examination, is crucial to determine readiness for pushing and to ensure safe delivery timing.

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Answer 7

Correct Answers:

"Make sure the newborn's diaper is snug.".

Rationale :

👶 After a Plastibell circumcision, a snug diaper helps maintain gentle pressure at the surgical site, promoting clot formation and reducing bleeding risk.

👶 The Plastibell device will fall off naturally within 5–8 days, and tight diapering supports the healing process without manual removal.

👶 Care instructions focus on keeping the area clean, applying gentle care, and avoiding interventions that could dislodge the ring early.

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Answer 8

Correct Answers:

The client is changing the perineal pad once daily.

Rationale :

🩸 Changing a perineal pad only once daily increases the risk of infection, which can delay wound healing after a perineal laceration.

🩸 Frequent pad changes are necessary to prevent bacterial growth in the moist perineal area, especially after a tear or episiotomy.

🩸 Proper hygiene and frequent pad replacement are key components in promoting optimal healing and preventing complications like abscess formation.

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Answer 9

Correct Answers:

"l should avoid becoming pregnant for at least 1 month following the immunization.".

Rationale :

🚫 The rubella vaccine is a live attenuated virus, and pregnancy should be avoided for at least 28 days post-vaccination to minimize fetal risks.

🚫 Conception soon after rubella vaccination could theoretically expose the fetus to congenital rubella syndrome, leading to serious anomalies.

🚫 Patient education must stress effective contraception use during the post-vaccination period to safeguard fetal health.

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Answer 10

Correct Answers:

Puncture the lateral side of the heel for the procedure.

Rationale :

🦶 The lateral or medial aspects of the newborn's heel are safe sites for heel sticks, avoiding damage to the calcaneus bone in the center.

🦶 Proper puncture technique reduces the risk of osteomyelitis, nerve injury, and scarring, promoting better outcomes in newborn care.

🦶 After the puncture, gentle pressure should be applied to minimize bruising and enhance sample collection success.

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QLexNursing

1 :
A nurse is caring for a client who is in labor and experiences abruptio placenta. Which of the following findings should the nurse expect?

2 :
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

3 :
A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

4 :
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?

5 :
A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

6 :
A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

7 :
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following information should the nurse include?

8 :
A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

9 :
A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

10 :
A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is caring for a client who is in labor and experiences abruptio placenta. Which of the following findings should the nurse expect?

2 : A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

3 : A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

4 : 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?

5 : A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

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

7 : A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following information should the nurse include?

8 : A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

9 : A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

10 : A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

1 :
A nurse is caring for a client who is in labor and experiences abruptio placenta. Which of the following findings should the nurse expect?

2 :
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

3 :
A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

4 :
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?

5 :
A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

6 :
A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

7 :
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following information should the nurse include?

8 :
A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

9 :
A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

10 :
A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?