Question

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Answer 1

Correct Answers:

Disseminated intravascular coagulation

Rationale :

🟥 Abruptio placentae can release large amounts of thromboplastin into maternal circulation, triggering widespread clotting followed by a depletion of clotting factors.

🟥 This leads to DIC, which manifests with petechiae, oozing at IV sites, and bleeding.

🟥 DIC is a life-threatening complication that requires prompt recognition and intervention with blood products and heparin in some cases.

🟥 It reflects a consumptive coagulopathy, where clots and bleeding occur simultaneously.

🟥 Nurses should be alert to early signs like uncontrolled bleeding and bruising.

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Answer 2

Correct Answers:

Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Observe the lochia during palpation of fundus.
Administer methylergonovine maleate if uterus is boggy.

Rationale :

Massage a firm fundus

🟢 Even if the fundus feels firm, gentle massage may be used to maintain uterine tone and encourage continued contraction, particularly in the first hours after delivery.

🟢 This helps prevent uterine atony, a leading cause of postpartum hemorrhage.

🟢 However, over-massaging a firm uterus is avoided unless clinically indicated.

🟢 Regular assessments and light stimulation help support normal involution of the uterus.

Determine whether the fundus is midline

🟢 A midline position of the uterus indicates that the bladder is not distended and that the uterus is well-positioned to contract effectively.

🟢 If the fundus is deviated to the side, it may suggest a full bladder, which can impede uterine contraction and increase bleeding risk.

🟢 Assessing fundal position is a standard step in postpartum assessments.

🟢 It helps determine if additional interventions such as encouraging voiding are necessary.

Document fundal height

🟢 Measuring and documenting fundal height helps monitor uterine involution, or the gradual return of the uterus to its pre-pregnancy size.

🟢 It provides a reference for comparison over time, especially when identifying delayed involution or hemorrhage.

🟢 Accurate documentation ensures continuity of care between shifts and providers.

🟢 Fundal height is typically measured in relation to the umbilicus (e.g., “1 fingerbreadth below the umbilicus”).

Observe the lochia during palpation of fundus

🟢 Lochia is assessed in terms of amount, color, and consistency during and after fundal palpation.

🟢 Increased bleeding during palpation may indicate uterine atony or retained placental fragments.

🟢 Monitoring lochia helps identify early signs of postpartum hemorrhage.

🟢 Nurses should document and report saturation patterns or presence of clots.

Administer methylergonovine maleate if uterus is boggy

🟢 A boggy uterus signals uterine atony, which is a critical cause of excessive postpartum bleeding.

🟢 Methylergonovine (Methergine) is a uterotonic that stimulates sustained uterine contractions.

🟢 It helps firm the uterus and reduce blood loss, especially when initial fundal massage is ineffective.

🟢 Before administering, the nurse must ensure the client's blood pressure is within safe limits, as the medication can elevate BP.

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Answer 3

Correct Answers:

The lowermost portion of the fetus is at the level of the ischial spines.

Rationale :

🔵 A 0 station indicates the presenting part is engaged in the pelvis at the level of the ischial spines.

🔵 This is the reference point used to determine descent during labor (station ranges from -5 to +5).

🔵 Engagement at 0 station shows the fetus is entering the true pelvis, progressing toward delivery.

🔵 This station helps guide delivery decisions and monitor descent during each contraction.

🔵 No other anatomical interpretations (e.g., fontanel or diameter passage) apply to the definition of 0 station.

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Answer 4

Correct Answers:

A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache

Rationale :

🟣 These are classic signs of worsening preeclampsia, indicating possible impending eclampsia or hepatic involvement (HELLP syndrome).

🟣 Epigastric pain suggests liver distention and should be reported immediately to avoid seizures or liver rupture.

🟣 A severe, unresolved headache reflects central nervous system involvement, increasing seizure risk.

🟣 These symptoms warrant urgent evaluation, including liver function tests, magnesium sulfate therapy, and possible delivery planning.

🟣 Reporting such findings ensures prompt, life-saving intervention.

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Answer 5

Correct Answers:

Blood pressure 80/56 mm Hg.

Rationale :

🟡 Hypotension is a priority concern with epidural analgesia due to vasodilation and decreased venous return.

🟡 A drop in blood pressure can compromise placental perfusion, endangering both mother and fetus.

🟡 This finding requires immediate intervention such as IV fluid bolus, positioning, and possibly vasopressors.

🟡 Other symptoms like itching and fever are common side effects but not life-threatening.

🟡 Prioritizing maternal circulation maintains fetal oxygenation and prevents further complications.

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Answer 6

Correct Answers:

Assist the client to breathe into a paper bag.

Rationale :

🔴 Pattern-paced breathing can lead to hyperventilation, causing respiratory alkalosis with symptoms like tingling and dizziness.

🔴 Breathing into a paper bag allows the client to re-inhale carbon dioxide, correcting the imbalance.

🔴 This restores acid-base equilibrium and resolves symptoms rapidly.

🔴 Nurses should recognize signs of hyperventilation early and avoid instructing clients to breathe faster.

🔴 This simple intervention is safe, fast, and effective.

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Answer 7

Correct Answers:

An excessive amount of amniotic fluid is present.

Rationale :

🟠 Polyhydramnios is defined as amniotic fluid > 2,000 mL, which can result from maternal diabetes, fetal anomalies, or twin-to-twin transfusion.

🟠 It increases the risk of preterm labor, cord prolapse, and postpartum hemorrhage.

🟠 The condition can stretch the uterus excessively and lead to malpresentation or poor fetal engagement.

🟠 It is diagnosed via ultrasound measurement of amniotic fluid index (AFI) or deepest pocket assessment.

🟠 Polyhydramnios is a fluid-related issue, not a multiple gestation or AFP-specific condition.

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Answer 8

Correct Answers:

Position the client on her side.

Rationale :

🔹 Late decelerations are caused by uteroplacental insufficiency, and the priority intervention is to improve uteroplacental perfusion.

🔹 Placing the client in a lateral position helps relieve pressure on the vena cava, enhancing blood flow to the placenta.

🔹 This is often the first step in managing non-reassuring fetal heart patterns before escalating interventions.

🔹 Repositioning may correct the decelerations and prevent fetal hypoxia.

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Answer 9

Correct Answers:

Uteroplacental insufficiency

Rationale :

⏺️ Late decelerations occur after the peak of the contraction and are due to impaired oxygen exchange across the placenta.

⏺️ This indicates the fetus may not be receiving adequate oxygenation during contractions.

⏺️ Common causes include maternal hypotension, post-term pregnancy, or placental aging.

⏺️ Persistent late decelerations require intervention to prevent fetal distress or acidosis.

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Answer 10

Correct Answers:

Weakened uterine contractions

Rationale :

🔹 Terbutaline is a beta-adrenergic agonist used as a tocolytic to suppress preterm labor.

🔹 It works by relaxing uterine smooth muscle, leading to weakened or reduced contractions.

🔹 Expected maternal side effects may include tachycardia, palpitations, and tremors, not low blood glucose.

🔹 Close monitoring of both maternal and fetal vitals is necessary during administration.

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QLexNursing

1 :
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

2 :
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

3 :
Nurse is assessing a client who is in active labor and notes that the presenting part is at O station. Which of the following is the correct Interpretation of this clinical finding?

4 :
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

5 :
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

6 :
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

8 :
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

9 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

10 :
A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?

QLexNursing

1 : A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

2 : A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

3 : Nurse is assessing a client who is in active labor and notes that the presenting part is at O station. Which of the following is the correct Interpretation of this clinical finding?

4 : A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

5 : A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

6 : A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

7 : A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

8 : A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

9 : A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

10 : A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?

1 :
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

2 :
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

3 :
Nurse is assessing a client who is in active labor and notes that the presenting part is at O station. Which of the following is the correct Interpretation of this clinical finding?

4 :
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

5 :
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

6 :
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

8 :
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

9 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

10 :
A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?