Question

A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

Answer 1

Correct Answers:

Cervical dilation

Rationale :

🎭 Cervical dilation during the first trimester is a critical indicator of imminent spontaneous abortion.

🎭 At 12 weeks gestation, the cervix should remain closed to maintain the pregnancy.

🎭 Dilation suggests that the cervix is preparing to expel the fetus, which is not expected this early.

🎭 This finding is more severe than spotting or mild cramping and requires immediate provider notification.

🎭 Early cervical changes indicate that pregnancy loss may be progressing without intervention.

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Answer 2

Correct Answers:

Respiratory rate 10/min

Rationale :

✔️ A respiratory rate of 10/min indicates respiratory depression, a known side effect of butorphanol.

✔️ Opioid agonist-antagonist medications like butorphanol can suppress the medullary respiratory center.

✔️ This adverse effect requires immediate provider notification and possibly withholding further doses.

✔️ It is important to monitor oxygenation and respiratory status after administration.

✔️ This rate is below normal and could lead to hypoventilation and hypoxia in both mother and fetus.

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Answer 3

Correct Answers:

Make a loud noise above the newborn.

Rationale :

💎 The Moro reflex is elicited by a sudden change in the infant’s environment, such as a loud sound.

💎 It triggers the infant to extend the arms, fingers, and legs, then retract in a startled response.

💎 This reflex is a normal neurologic finding and should be present in a term newborn.

💎 Absence or asymmetry may indicate neurologic or musculoskeletal problems.

💎 It is typically present from birth to around 4 to 6 months of age.

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Answer 4

Correct Answers:

Fortified soy milk

Rationale :

✳️ Vitamin B2 (riboflavin) is often found in fortified plant-based milk alternatives like soy milk.

✳️ This is a reliable source for clients following a vegan diet, which excludes dairy and animal products.

✳️ Riboflavin plays a crucial role in cellular metabolism and energy production.

✳️ Vegans are at risk for B2 deficiency and require fortified foods or supplements.

✳️ Raw vegetables and citrus lack significant amounts of riboflavin.

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Answer 5

Correct Answers:

History of uterine atony
Labor induction with oxytocin
Vacuum-assisted delivery

Rationale :

History of uterine atony

🎀 Clients with a history of uterine atony are at high risk for postpartum hemorrhage due to the uterus failing to contract effectively after delivery.

🎀 This condition leads to continued bleeding because the uterus cannot compress blood vessels at the placental site.

🎀 Prior episodes increase the likelihood of recurrence in subsequent births, requiring close monitoring.

Labor induction with oxytocin

🎀 Oxytocin-induced labor can overstimulate the uterus, causing uterine muscle fatigue and reducing the effectiveness of postpartum contractions.

🎀 This increases the risk of atony and hemorrhage in the immediate postpartum period.

🎀 Continuous oxytocin use may also mask poor uterine tone, leading to delayed detection of bleeding.

Vacuum-assisted delivery

🎀 Instrumental deliveries are linked to greater trauma, including genital tract lacerations and uterine exhaustion.

🎀 Vacuum assistance may also cause retained placental fragments or ineffective uterine involution.

🎀 These factors collectively contribute to a higher chance of postpartum hemorrhage.

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Answer 6

Correct Answers:

Single palmar creases.

Rationale :

🪷 A single palmar crease is often associated with chromosomal abnormalities, such as Down syndrome.

🪷 It is considered a congenital anomaly that warrants further diagnostic follow-up.

🪷 Although not diagnostic on its own, it is a significant physical marker that the provider must evaluate.

🪷 Other findings like subconjunctival hemorrhage and transient cyanosis are typically benign.

🪷 Early identification of syndromic features supports timely interventions and referrals.

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Answer 7

Correct Answers:

3

Rationale :

✴️Convert first

▶️The client weighs 132 lb, which is 60 kg (132 ÷ 2.2).

✴️ Dose required = 2 mg/kg × 60 kg = 120 mg.

✴️ Supplied = 40 mg/mL

Calculation

🔺→ 120 mg ÷ 40

= 3 mL to administer.

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Answer 8

Correct Answers:

Continue to monitor the client.

Rationale :

◻️ Early decelerations mirror contractions and are typically caused by fetal head compression, not hypoxia.

◻️ This is a benign and expected finding during active labor, especially with internal monitoring.

◻️ No intervention is required; instead, ongoing observation and documentation should be done.

◻️ Intervening unnecessarily could disrupt labor progress and increase risk.

◻️ It is important to differentiate early decels from late or variable decels, which are more concerning.

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Answer 9

Correct Answers:

Maintain scheduled mealtimes for yourself.

Rationale :

🔺 Breastfeeding and insulin use can lead to fluctuating glucose levels, so meal regularity is key.

🔺 Skipping meals can result in hypoglycemia, especially during the energy-demanding postpartum period.

🔺 The nurse should emphasize the importance of consistent carbohydrate intake with insulin management.

🔺 Blood glucose may drop faster during breastfeeding due to increased energy expenditure.

🔺 Managing mealtimes helps maintain safe glycemic control while nursing.

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Answer 10

Correct Answers:

Administer a bolus infusion of lactated Ringers.

Rationale :

✨ Maternal hypotension following an epidural is usually due to vasodilation from sympathetic blockade.

✨ Administering an IV fluid bolus increases circulating volume and improves blood pressure.

✨ This promotes adequate placental perfusion and oxygen delivery to the fetus.

✨ Lactated Ringer’s is commonly used due to its electrolyte balance and isotonic nature.

✨ Early correction of hypotension prevents fetal bradycardia and hypoxia.

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QLexNursing

1 :
A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

2 :
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

3 :
A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

4 :
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B2. Which of the following foods should the nurse recommend?

5 :
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)

6 :
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

8 :
A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?

9 :
A nurse is providing teaching to a postpartum client who has type 1 diabetes mellitus and is breastfeeding her newborn. Which of the following instructions should the nurse give the client?

10 :
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

2 : A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

3 : A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

4 : A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B2. Which of the following foods should the nurse recommend?

5 : A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)

6 : A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

8 : A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?

9 : A nurse is providing teaching to a postpartum client who has type 1 diabetes mellitus and is breastfeeding her newborn. Which of the following instructions should the nurse give the client?

10 : A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?

1 :
A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

2 :
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

3 :
A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

4 :
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B2. Which of the following foods should the nurse recommend?

5 :
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)

6 :
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

8 :
A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?

9 :
A nurse is providing teaching to a postpartum client who has type 1 diabetes mellitus and is breastfeeding her newborn. Which of the following instructions should the nurse give the client?

10 :
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?