Question

Adllent, 1 day postpartum, is being monitored after a postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?

Answer 1

Correct Answers:

Urine output of 200 mL for the past 8 hours.

Rationale :

🔴 A urine output of only 200 mL over 8 hours indicates oliguria, which may be a sign of hypovolemia or acute kidney injury following postpartum hemorrhage (PPH).

🔴 Adequate renal perfusion depends on circulating volume, and reduced urine output is often an early indicator of continued blood loss or insufficient fluid resuscitation.

🔴 The expected urine output is at least 30 mL/hour, or 240 mL over 8 hours—anything less requires immediate assessment and reporting.

🔴 Ongoing hypovolemia may not be evident through vital signs alone, so urine output is a critical indicator of internal volume status.

🔴 Reporting this finding promptly helps initiate interventions to restore perfusion, prevent organ dysfunction, and avoid further maternal morbidity.

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Answer 2

Correct Answers:

Abruptio placentae

Rationale :

🔴 Abruptio placentae is the premature separation of the placenta from the uterine wall and is a serious complication that can occur following abdominal trauma, such as from a motor vehicle crash, even if there are no visible injuries.

🔴 This condition can lead to fetal hypoxia, maternal hemorrhage, and preterm labor, making it a medical emergency that warrants close fetal and maternal monitoring.

🔴 Symptoms may include abdominal pain, uterine tenderness, vaginal bleeding, or even contractions; however, in some cases, it can occur silently without initial symptoms.

🔴 Because the risk of placental abruption increases with blunt force trauma, observation and continuous fetal monitoring are necessary to detect any signs of fetal distress or bleeding.

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Answer 3

Correct Answers:

They are below the 10th percentile on gestational growth charts.

Rationale :

🟢 Small for gestational age (SGA) refers to newborns whose birth weight falls below the 10th percentile for their gestational age, meaning they are smaller than 90% of infants at the same gestational stage.

🟢 SGA infants may be term, preterm, or post-term, so gestational age alone is not the defining factor.

🟢 Causes of SGA are multifactorial, including placental insufficiency, maternal hypertension, infections, smoking, malnutrition, and genetic conditions—not limited to placental malfunction.

🟢 A weight less than 2500 grams (5.5 lbs) can indicate low birth weight but is not diagnostic of SGA without referencing gestational age.

🟢 Growth charts based on gestational age are essential tools for identifying and managing SGA infants to monitor for complications like hypoglycemia, thermoregulation issues, and delayed development.

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Answer 4

Correct Answers:

Have the parent fold the infant's arms across the chest.

Rationale :

🟣 Sneezing, yawning, and limb extension are signs of stress or overstimulation in a preterm infant, especially when held or handled.

🟣 These behaviors indicate the infant is struggling to maintain neurodevelopmental stability.

🟣 Folding the infant’s arms across the chest, also known as "containment" or facilitated tucking, is a developmentally supportive care strategy that promotes self-regulation, comfort, and neurological calming.

🟣 This gentle containment mimics the intrauterine posture, reducing stress responses and helping the infant return to a flexed, midline position, which conserves energy and supports neurologic maturation.

🟣 This approach allows the parent to remain involved in the infant’s care while promoting neurobehavioral organization, without resorting to stopping interaction or excessive warming, unless temperature instability is present.

🟣 Encouraging positive touch with structured boundaries helps preterm infants adapt better to stimuli and develop healthy neurobehavioral patterns.

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Answer 5

Correct Answers:

120 to 160

Rationale :

🟢 The normal apical pulse rate for a full-term, quiet, alert newborn ranges from 120 to 160 beats per minute.

🟢This reflects the typical resting heart rate during the newborn period.

🟢 Variations can occur with activity or crying—rates may rise to up to 180 bpm when active or decrease slightly during deep sleep, but 120–160 bpm is the baseline expected range during calm, alert states.

🟢 The apical pulse is the most accurate site to assess newborn heart rate due to their thin chest wall and fast heart rate, and it is typically auscultated at the 4th intercostal space left midclavicular line.

🟢 Accurate heart rate monitoring is essential to detect cardiopulmonary issues, guide resuscitation if needed, and assess overall neonatal stability.

🟢 Deviations outside this range should prompt further assessment for causes such as infection, hypoxia, or congenital heart conditions.

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Answer 6

Correct Answers:

Test for blood glucose level.

Rationale :

🔴 A newborn of an insulin-dependent diabetic mother is at high risk for hypoglycemia due to hyperinsulinemia developed in utero.

🔴After birth, the sudden removal of maternal glucose supply can cause a sharp drop in blood glucose levels.

🔴 Symptoms such as jitteriness, irritability, and a high-pitched cry are classic early signs of neonatal hypoglycemia and warrant immediate blood glucose testing to confirm diagnosis and guide treatment.

🔴 This action is the top priority because prompt identification of hypoglycemia is essential to prevent seizures, brain damage, and long-term neurological deficits.

🔴 While starting IV glucose may be appropriate after confirming hypoglycemia, the priority is to objectively measure the blood sugar first.

🔴 Early detection ensures rapid intervention with oral or IV glucose depending on severity, preventing escalation to more severe complications.

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Answer 7

Correct Answers:

I will be certain to empty the litter boxes regularly.

Rationale :

🔴 Handling cat litter is a major source of exposure to Toxoplasma gondii, the parasite responsible for toxoplasmosis, which can lead to serious fetal complications including miscarriage, hydrocephalus, and chorioretinitis.

🔴 Pregnant women should avoid changing litter boxes entirely if possible, and if unavoidable, they must use gloves and wash hands thoroughly afterward to reduce the risk.

🔴 The statement indicates a misunderstanding—emptying the litter box more often does not reduce the risk; in fact, it increases the chance of exposure to the parasite.

🔴 In contrast, washing produce, avoiding raw eggs, and thoroughly cooking meat are all appropriate preventive measures against toxoplasmosis and other infections.

🔴 This statement requires further teaching to emphasize the importance of avoiding exposure to cat feces during pregnancy.

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Answer 8

Correct Answers:

Amniotic fluid and maternal blood pose risks to us.

Rationale :

🔴 Glove use when handling a newborn is essential to protect healthcare personnel from potential exposure to maternal body fluids, including amniotic fluid and blood, which may carry infectious pathogens (e.g., HIV, hepatitis B/C).

🔴 Even though the newborn may seem “unexposed,” the delivery process involves direct contact with maternal secretions, posing a risk of transmission to caregivers.

🔴 This explanation helps the student nurse understand the self-protective aspect of glove use, especially during the immediate postpartum period when exposure risk is high.

🔴 The use of gloves falls under standard precautions, which apply to all clients and body fluids, but focusing on the specific biological hazard provides a more informative teaching point.

🔴 Educating students on the rationale behind protective practices reinforces safe infection control behavior.

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Answer 9

Correct Answers:

Initiate IV access.

Rationale :

🔴 The client is at 38 weeks gestation with a large amount of painless, bright red vaginal bleeding, which is highly suggestive of placenta previa—a condition where the placenta partially or completely covers the cervix.

🔴 Her vital signs show hypotension and tachycardia, indicating hemodynamic instability and possible hypovolemia due to blood loss, making fluid resuscitation a top priority.

🔴 The first and most critical intervention is to establish IV access, preferably with a large-bore catheter, to enable rapid fluid and blood product administration if needed.

🔴 While preparing for surgery or obtaining consent may become necessary, stabilizing the client’s circulatory status must come first according to ABCs (Airway, Breathing, Circulation).

🔴 Early IV access allows for prompt intervention, lab draws, and possible emergency cesarean delivery if maternal or fetal condition deteriorates.

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Answer 10

Correct Answers:

Total placenta previa

Rationale :

🔴 In total placenta previa, the placenta completely covers the cervical os, which creates a mechanical obstruction to vaginal delivery and poses a severe hemorrhage risk during labor.

🔴 Attempting vaginal delivery in such cases can lead to catastrophic maternal and fetal bleeding, making cesarean section the only safe delivery method.

🔴 This condition is diagnosed via ultrasound, and once confirmed as “total,” a scheduled C-section at around 36–37 weeks is typically planned unless earlier delivery is indicated.

🔴 Other conditions like preeclampsia or partial abruption may require C-section depending on severity, but they do not always mandate it.

🔴 Ectopic pregnancy is not delivered via cesarean—it is managed surgically or medically before fetal viability is reached.

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QLexNursing

1 :
Adllent, 1 day postpartum, is being monitored after a postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?

2 :
A woman who is 8 months pregnant is brought to the emergency department after a serious motor vehicle crash. Although she has no apparent injuries, she is admitted to the hospital for observation for which complication?

3 :
Which is true about newborns classified as small for gestational age (SGA)?

4 :
The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best?

5 :
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is _ beats/min.

6 :
Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?

7 :
A nurse has taught a pregnant woman about toxoplasmosis. What statement by the patient indicates a need for further instruction?

8 :
The student nurse asks why gloves are needed when handling a newborn because the newborn "hasn’t been exposed to anything". What response by the nurse is best?

10 :
Which maternal condition always necessitates delivery by cesarean section?

QLexNursing

1 : Adllent, 1 day postpartum, is being monitored after a postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?

2 : A woman who is 8 months pregnant is brought to the emergency department after a serious motor vehicle crash. Although she has no apparent injuries, she is admitted to the hospital for observation for which complication?

3 : Which is true about newborns classified as small for gestational age (SGA)?

4 : The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best?

5 : While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is _ beats/min.

6 : Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?

7 : A nurse has taught a pregnant woman about toxoplasmosis. What statement by the patient indicates a need for further instruction?

8 : The student nurse asks why gloves are needed when handling a newborn because the newborn "hasn’t been exposed to anything". What response by the nurse is best?

10 : Which maternal condition always necessitates delivery by cesarean section?

1 :
Adllent, 1 day postpartum, is being monitored after a postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?

2 :
A woman who is 8 months pregnant is brought to the emergency department after a serious motor vehicle crash. Although she has no apparent injuries, she is admitted to the hospital for observation for which complication?

3 :
Which is true about newborns classified as small for gestational age (SGA)?

4 :
The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best?

5 :
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is _ beats/min.

6 :
Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?

7 :
A nurse has taught a pregnant woman about toxoplasmosis. What statement by the patient indicates a need for further instruction?

8 :
The student nurse asks why gloves are needed when handling a newborn because the newborn "hasn’t been exposed to anything". What response by the nurse is best?

10 :
Which maternal condition always necessitates delivery by cesarean section?