Question

A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Monitor fetal heart rate tracings.

Rationale :

💎In abruptio placentae, the placenta prematurely separates from the uterine wall, leading to compromised fetal oxygenation.

💎Continuous fetal heart rate (FHR) monitoring is essential to assess for signs of fetal distress such as late decelerations, tachycardia, or bradycardia.

💎The FHR pattern provides critical information about uteroplacental perfusion and the effectiveness of interventions to stabilize the mother and fetus.

💎Maternal signs such as abdominal pain, uterine rigidity, and vaginal bleeding often coincide with nonreassuring FHR patterns, indicating worsening abruption.

💎Monitoring allows the nurse to promptly report abnormalities to the provider, who may decide on emergency delivery if fetal distress persists.

💎Other interventions (like oxytocin or vaginal exams) are contraindicated until stabilization and diagnostic confirmation, as they can worsen separation or hemorrhage.

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Answer 2

Correct Answers:

Administer Rho[D] immune globulin after the procedure.

Rationale :

♦️An amniocentesis involves inserting a needle into the amniotic sac, which can cause fetomaternal hemorrhage — the mixing of fetal and maternal blood.

♦️In an Rh-negative client, this poses a risk for isoimmunization, where maternal antibodies may form against Rh-positive fetal red blood cells.

♦️To prevent this, the nurse must administer Rho(D) immune globulin (RhoGAM) after the procedure to neutralize any fetal Rh-positive cells that may have entered the maternal circulation.

♦️This action protects future pregnancies from hemolytic disease of the newborn caused by Rh incompatibility.

♦️The medication is given within 72 hours of the procedure, intramuscularly, as prescribed.

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Answer 3

Correct Answers

Client reports ringing in ears [ Indication of Worsening Condition ]
FHR 80/min with absent variability [ Indication of Worsening Condition ]
PT 12 seconds [ Indication of Improving Condition ]
Moderate maternal bleeding [ Indication of Worsening Condition ]
BP 180/100 mmHg [ Indication of Worsening Condition ]
Client reports sharp, stabbing abdominal pain [ Indication of Worsening Condition ]

Rationale :

Client reports ringing in ears — Indication of Worsening Condition

💎 Tinnitus (ringing in the ears) is a classic warning sign of severe hypertension in preeclampsia and HELLP syndrome.

💎 It occurs due to cerebral vasospasm and increased intracranial pressure, reflecting neurological irritation and reduced cerebral perfusion.

💎 Persistent or worsening ringing may precede seizure activity (eclampsia), indicating worsening central nervous system involvement.

💎 The nurse must immediately monitor blood pressure, assess for headache or visual changes, and prepare for antihypertensive and seizure prophylaxis (e.g., magnesium sulfate).

FHR 80/min with absent variability — Indication of Worsening Condition

💎 A fetal heart rate (FHR) of 80/min with absent variability indicates severe fetal hypoxia or distress.

💎In HELLP syndrome, placental insufficiency results from vasoconstriction and endothelial damage, reducing oxygen and nutrient delivery to the fetus.

💎Absent variability means the autonomic nervous system of the fetus is no longer compensating, showing impending fetal compromise or death.

💎This finding requires immediate intrauterine resuscitation (positioning, oxygen, fluids) and likely emergency delivery if unresolved.

PT 12 seconds — Indication of Improving Condition

💎 A prothrombin time (PT) of 12 seconds is within the normal range (11–13.5 sec), indicating adequate liver function and clotting ability.

💎In worsening HELLP, liver dysfunction typically causes prolonged PT and bleeding tendencies.

💎A normal PT therefore reflects stabilization of hepatic enzyme activity and coagulation factors, signaling that treatment is working and liver recovery is underway.

💎It also means risk for DIC is reduced, and maternal blood loss is better controlled.

Moderate maternal bleeding — Indication of Worsening Condition

💎 In HELLP syndrome, low platelet counts and impaired coagulation increase the risk for spontaneous bleeding.

💎 Moderate bleeding can indicate the onset of DIC, where widespread clotting consumes platelets and clotting factors, leading to hemorrhage.

💎 This also places the mother at risk for hypovolemic shock, anemia, and organ failure.

💎 The nurse should immediately assess vital signs, bleeding sites, and prepare to administer platelets or plasma products per provider orders.

BP 180/100 mm Hg — Indication of Worsening Condition

💎 A blood pressure of 180/100 mm Hg demonstrates severe, uncontrolled hypertension, hallmark of worsening preeclampsia or HELLP syndrome.

💎 Such extreme pressure damages endothelial cells, worsening vascular permeability, edema, and organ ischemia (especially liver and kidneys).

💎 This level of hypertension increases the risk of stroke, placental abruption, and eclampsia.

💎 Emergency interventions include antihypertensive therapy (labetalol, hydralazine) and magnesium sulfate for seizure prevention.

Client reports sharp, stabbing abdominal pain — Indication of Worsening Condition

💎Sudden sharp, stabbing pain in the upper right quadrant or epigastric area is a hallmark sign of liver capsule distention due to subcapsular hematoma or even hepatic rupture.

💎 This is a medical emergency and indicates rapidly worsening HELLP syndrome with risk of internal bleeding and hypovolemic shock.

💎 The pain often radiates to the shoulder or back, and may be accompanied by nausea, vomiting, or hypotension as bleeding progresses.

💎 Immediate evaluation, imaging, and surgical intervention are required to prevent maternal mortality.

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Answer 4

Correct Answers:

The newborn has fewer than four wet diapers in 24 hr.

Rationale :

💧By day 4–5 of life, a well-hydrated newborn should produce at least 6 wet diapers per day; fewer than 4 suggests inadequate intake or dehydration.

💧Insufficient urine output can indicate poor breastfeeding effectiveness, formula underfeeding, or illness that reduces perfusion to the kidneys.

💧Dehydration in newborns may also present with uric acid crystals, weight loss >10%, dry mucous membranes, and lethargy, all of which warrant prompt evaluation.

💧Early provider notification helps prevent complications such as hypernatremia, hypoglycemia, and failure to thrive.

💧The safest teaching is to track diapers and seek care immediately if wet diapers are below age-appropriate targets.

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Answer 5

Correct Answers:

Weigh the newborn daily.
Instruct the parent to avoid discomfort.
Swaddle the newborn with discomfort.
Maintain a low stimulation rate.

Rationale :

Weigh the newborn daily

🍼 Daily weights (same time, same scale, same clothing/diaper) provide an objective trend of intake and hydration in the first week of life.

🍼 A normal physiologic weight loss is ≤7–10% by day 3–5 with regain by ~2 weeks; crossing these limits signals feeding problems or dehydration.

🍼 Early identification of excess weight loss prompts lactation support, feed frequency adjustments, or evaluation for underlying illness.

🍼 Weight trends correlate with other markers (e.g., wet diapers, stool frequency, clinical vigor), improving clinical decision-making.

🍼 Consistent measurement technique reduces error and ensures that subtle changes are detected early before complications develop.

Instruct the parent to avoid discomfort (minimize overstimulation)

🍼 Newborns have immature neurologic regulation; bright lights, loud noise, and excess handling increase energy expenditure and feeding fatigue.

🍼 Teaching caregivers to cluster care, use soft voices, and pace interactions preserves sleep architecture and supports growth.

🍼 Reducing overstimulation lowers stress cues (finger splay, color change, yawning/hiccups) and stabilizes heart rate, respirations, and temperature.

🍼 Comfort-promoting strategies (skin-to-skin, cue-based feeds, gentle rocking) decrease crying and improve feeding readiness.

🍼 The goal is to keep the newborn in a quiet-alert state for feeding and to protect sleep, which is crucial for neurodevelopment.

Swaddle the newborn for comfort

🍼 Swaddling provides containment that mimics the intrauterine environment, reducing Moro (startle) reflex and crying.

🍼 Proper technique (arms contained, hips flexed/abducted to avoid dysplasia, no overheating) improves self-soothing and sleep duration.

🍼 By decreasing stress and caloric burn, swaddling supports weight gain and thermoregulation.

🍼 Swaddling before painful or stimulating care can reduce procedural distress and help with state regulation.

🍼 Parents should be taught safe swaddling and to stop when rolling begins to maintain safe sleep practices.

Maintain a low-stimulation environment

🍼 A dim, quiet environment with gentle handling helps maintain physiologic stability (color, tone, respirations), especially in the first days.

🍼 Low stimulation conserves glycogen stores and reduces oxygen demand, supporting euglycemia and temperature control.

🍼 Pairing a calm setting with skin-to-skin and cue-based feeding improves milk transfer and maternal–infant bonding.

🍼 Minimizing alarms, limiting visitors, and spacing cares prevent sensory overload that can disrupt feeding and sleep–wake cycles.

🍼 This approach fosters neurobehavioral organization, which underpins effective feeding, growth, and early learning.

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Answer 6

Correct Answers:

Tachycardia

Rationale :

🚑In postpartum hemorrhagic shock, the earliest compensatory response to acute intravascular volume loss is sinus tachycardia to maintain cardiac output.

🚑As blood volume falls, baroreceptor-mediated sympathetic activation increases heart rate and contractility before blood pressure declines.

🚑Persistent tachycardia with cool, clammy skin, delayed capillary refill, and anxiety signals worsening perfusion.

🚑Untreated, shock progresses to hypotension, oliguria, altered mentation, and metabolic acidosis.

🚑Immediate priorities include uterine massage, uterotonics, two large-bore IVs, blood products, and rapid source control, but the expected finding at recognition is tachycardia.

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Answer 7

Correct Answers:

Soft grunting noises with respiration

Rationale :

🫁Expiratory grunting is a sign of respiratory distress as the newborn attempts to maintain functional residual capacity and improve oxygenation.

🫁It often accompanies nasal flaring, retractions, or tachypnea and may indicate transient tachypnea, meconium aspiration, sepsis, or pneumonia.

🫁At 4 hours of life, grunting warrants prompt provider notification, assessment of oxygen saturation, and possible supplemental oxygen or imaging.

🫁Normal transition findings include acrocyanosis, pseudomenstruation (blood-tinged vaginal mucus in females), and positive Babinski—these do not require reporting.

🫁Early recognition prevents deterioration to hypoxemia, apnea, and hemodynamic instability.

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Answer 8

Correct Answers:

"Insert the diaphragm after you empty your bladder."

Rationale :

🩺Voiding before insertion reduces the risk of urinary tract infection by decreasing bacterial load and minimizing urethral pressure from the rim of the diaphragm.

🩺Proper use includes applying spermicide to the dome/rim, ensuring the cervix is fully covered, and performing a finger sweep to confirm position.

🩺The diaphragm must remain in place for at least 6 hours after intercourse (but no longer than 24 hours) to maintain spermicidal contact.

🩺Avoid oil-based lubricants, which degrade latex/silicone and reduce contraceptive effectiveness; use water-based only.

🩺Recheck fit after weight change ≥10 lbs (≈4.5 kg), birth, or pelvic surgery to maintain seal integrity.

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Answer 9

Correct Answers:

Prepare to initiate cardiopulmonary resuscitation.

Rationale :

🫀Amniotic fluid embolism (AFE) causes sudden cardiopulmonary collapse and DIC; immediate priorities are high-flow oxygen, airway control, left uterine displacement, and readiness for CPR.

🫀If maternal cardiac arrest occurs, start ACLS with pregnancy modifications (manual uterine displacement) and target perimortem cesarean within 5 minutes if no ROSC to improve maternal–fetal outcomes.

🫀Early preparation ensures defibrillator access, code medications, massive transfusion protocol, and critical care team at bedside.

🫀Low-flow oxygen via nasal cannula is insufficient; patients require NRB 10–15 L/min or intubation.

🫀Fundal massage addresses atony, not the cardiopulmonary failure central to AFE; resuscitation readiness is decisive.

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Answer 10

Correct Answers:

"Syphilis can be cured with penicillin."

Rationale :

🧪Benzathine penicillin G is the treatment of choice for primary, secondary, and early latent syphilis, eradicating Treponema pallidum.

🧪Prompt therapy prevents progression to tertiary disease (gummas, cardiovascular, neurosyphilis) and reduces congenital transmission in pregnancy (after desensitization if allergic).

🧪Follow-up nontreponemal titers (e.g., RPR/VDRL) confirm adequate serologic response and detect reinfection.

🧪Patient education includes abstinence until lesions resolve and partners are tested/treated.

🧪Unlike some viral STIs without cures, syphilis is curable when treated appropriately and early.

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Findings 15 min Later	Unrelated to Diagnosis	Indication of Improving Condition	Indication of Worsening Condition
Client reports ringing in ears
FHR 80/min with absent variability
PT 12 seconds
Moderate maternal bleeding
BP 180/100 mmHg
Client reports sharp, stabbing abdominal pain

RN-Maternal Newborn 2023

No.

1 :
A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

2 :
A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?

3 :
A patient had repeat cesarean birth 3days ago.

Correct Answers

4 :
A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?

5 :
A nurse is caring for a newborn who is 5 days old. Which of the following actions are needed? Select all that apply.

6 :
A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?

7 :
A nurse is caring for a newborn 4 hr after their birth. Which of the following findings should the nurse report to the provider?

8 :
A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

9 :
A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

10 :
A nurse is teaching a group of clients about sexually transmitted infections. Which of the following client statements indicates an understanding of the teaching?

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RN-Maternal Newborn 2023

No.

1 : A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

2 : A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?

3 : A patient had repeat cesarean birth 3days ago.

Correct Answers

4 : A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?

5 : A nurse is caring for a newborn who is 5 days old. Which of the following actions are needed? Select all that apply.

6 : A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?

7 : A nurse is caring for a newborn 4 hr after their birth. Which of the following findings should the nurse report to the provider?

8 : A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

9 : A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

10 : A nurse is teaching a group of clients about sexually transmitted infections. Which of the following client statements indicates an understanding of the teaching?

1 :
A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

2 :
A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?

3 :
A patient had repeat cesarean birth 3days ago.

4 :
A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?

5 :
A nurse is caring for a newborn who is 5 days old. Which of the following actions are needed? Select all that apply.

6 :
A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?

7 :
A nurse is caring for a newborn 4 hr after their birth. Which of the following findings should the nurse report to the provider?

8 :
A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

9 :
A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

10 :
A nurse is teaching a group of clients about sexually transmitted infections. Which of the following client statements indicates an understanding of the teaching?