Question

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Painless, vaginal bleeding

Rationale :

🔴 Placenta previa occurs when the placenta partially or completely covers the cervical os, leading to disruption of placental vessels as the cervix dilates.

🔴 The hallmark sign is sudden onset of painless, bright red vaginal bleeding in the second or third trimester.

🔴 The uterus remains soft and non-tender, and fetal heart tones are usually present unless bleeding is severe.

🔴 Unlike placental abruption, placenta previa does not typically cause uterine rigidity or pain, unless complications arise.

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Answer 2

Correct Answers:

"I will drink water before the test until my bladder feels full."

Rationale :

🔹 Abdominal ultrasounds during early pregnancy require a full bladder to help lift the uterus out of the pelvis and provide better visualization of pelvic structures.

🔹 The acoustic window created by a full bladder allows for clearer ultrasound images by displacing the bowel and acting as a sound wave conductor.

🔹 Clients are often instructed to drink 1 quart (about 1 liter) of water about 1–2 hours before the procedure and not to void until after the scan is complete.

🔹 This preparation is essential especially for primigravid clients undergoing an early ultrasound where fetal structures may be more difficult to visualize.

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Answer 3

Correct Answers:

Uterine tenderness

Rationale :

🔷 Uterine tenderness is a hallmark clinical sign of endometritis, an infection of the endometrial lining of the uterus, typically occurring postpartum.

🔷 This condition commonly develops within the first 48 to 72 hours after delivery, especially following prolonged labor, cesarean birth, or premature rupture of membranes.

🔷 Clients may also present with fever, foul-smelling lochia, chills, malaise, and increased lochia—but uterine tenderness on palpation is one of the most specific and reliable indicators.

🔷 Prompt recognition and treatment with broad-spectrum IV antibiotics are essential to prevent complications such as sepsis or abscess formation.

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Answer 4

Correct Answers:

No Correct Answers Available !

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Answer 5

Correct Answers:

No Correct Answers Available !

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Answer 6

Correct Answers:

Contractions last 60 seconds

Rationale :

🔷 Oxytocin must be carefully titrated to avoid uterine tachysystole, defined as more than 5 contractions in 10 minutes, averaged over a 30-minute window.

🔷 Uterine tachysystole can reduce placental blood flow, leading to fetal hypoxia and non-reassuring heart rate patterns.

🔷 When more than 5 contractions occur in 10 minutes, the nurse should discontinue oxytocin immediately, initiate intrauterine resuscitation (e.g., position change, IV fluids, oxygen), and notify the provider.

🔷 This helps prevent uterine rupture, fetal compromise, and other labor complications from excessive uterine activity.

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Answer 7

Correct Answers:

"Your partner will apply steady pressure with a tennis ball to your lower back."

Rationale :

🟣 Counterpressure is a pain relief technique used during labor, especially beneficial for women experiencing back labor, which is often due to fetal occiput posterior position.

🟣 Applying steady, firm pressure with a tennis ball, fist, or heel of the hand to the sacral area helps relieve intense lower back pain caused by the pressure of the fetal head.

🟣 This technique is typically used during contractions and provides a non-pharmacologic comfort measure, often giving the laboring person a sense of control.

🟣 Involving the partner in applying counterpressure can also promote supportive labor involvement and enhance the birthing experience.

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Answer 8

Correct Answers:

The client has a fundal height of 38 cm.

Rationale :

🟠 At 32 weeks of gestation, the fundal height is expected to measure approximately 32 cm, correlating with the gestational age in centimeters (±2 cm).

🟠 A fundal height of 38 cm indicates excessive uterine growth, which may suggest polyhydramnios or fetal macrosomia—both of which are common complications of gestational diabetes mellitus (GDM).

🟠 Polyhydramnios increases the risk of preterm labor, placental abruption, and cord prolapse, and macrosomia raises concerns for birth trauma or the need for cesarean delivery.

🟠 This abnormal growth pattern should be reported promptly for further evaluation with ultrasound and glycemic management adjustment.

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Answer 9

Correct Answers:

"You can bathe and dress your baby if you'd like to."

Rationale :

🟣 Offering the option to bathe and dress the baby supports the family's grieving process and promotes a sense of connection and closure.

🟣 This approach demonstrates respectful, client-centered care and allows the parents to make meaningful memories during a tragic event.

🟣 Giving choices and validating the family's role fosters psychological healing and honors the loss with dignity and compassion.

🟣 The nurse should provide emotional support and avoid statements that assume or impose specific actions, emotions, or future outcomes.

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Answer 10

Correct Answers:

Single palmar creases

Rationale :

🟢 A single palmar crease (also called a simian crease) is a physical finding that may be associated with chromosomal abnormalities, such as Down syndrome (trisomy 21).

🟢 Although this can be a normal variant, especially in certain ethnic groups, its presence warrants further evaluation when identified in a newborn, especially if accompanied by other dysmorphic features.

🟢 Early recognition is important to initiate genetic testing, assess for potential congenital anomalies (e.g., cardiac defects), and arrange for multidisciplinary follow-up if needed.

🟢 The other findings listed are common and typically benign in the immediate newborn period, but a single palmar crease can be a red flag for underlying syndromes.

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QLexNursing

1 :
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

2 :
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

4 :
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)

5 :
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)

6 :
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?

7 :
A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

8 :
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

9 :
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

10 :
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?

QLexNursing

1 : A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

2 : A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

4 : A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)

5 : A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)

6 : A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?

7 : A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

8 : A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

9 : A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

10 : 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?

1 :
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

2 :
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

4 :
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)

5 :
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)

6 :
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?

7 :
A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

8 :
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

9 :
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

10 :
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?