51. A nurse in an antepartum clinic is caring for a client who is pregnant.

Medical History 0815:

Gravida 4 Para 3

33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in)
Weight 82 kg (180 lb)

BMI 30.6

3.2 kg (7 lb) weight gain over the last 2 weeks

Select the 4 assessment findings the nurse should report to the provider.

Deep tendon reflexes

Visual disturbances

Fetal heart rate

Blood pressure

Weight

Answer and Explanation

Correct Answer : C,D,E

Visual disturbances in a pregnant client could indicate conditions such as preeclampsia or gestational hypertension, which require immediate medical attention.

Monitoring the fetal heart rate is essential to assess fetal well-being, and any abnormalities in the fetal heart rate may require further evaluation by the provider.
Changes in blood pressure, especially elevated blood pressure, may indicate gestational hypertension or preeclampsia, which require monitoring and management by the provider. A significant weight gain of 3.2 kg (7 lb) over the last 2 weeks may indicate fluid retention or other issues that need assessment and intervention by the provider.

Deep tendon reflexes (option A) are not typically assessed routinely in antepartum care unless there are specific indications, such as signs of preeclampsia.

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Correct Answer is B

Explanation

Lochia rubra, which is bright red and may contain small clots, is the normal postpartum vaginal discharge that occurs during the first few days after childbirth. It indicates the shedding of the uterine lining and is expected during the early postpartum period. A midline and firm fundus at the level of the umbilicus suggests appropriate uterine involution, indicating that the uterus is contracting effectively to expel lochia and decrease in size.

Given these findings, there is no immediate concern requiring intervention.

A. Blunt force trauma B. Cigarette smoking C. Cocaine use D. Hypertension

Correct Answer is D

Explanation

The commonest risk factor for placenta abruption is hypertensive diseases in pregnancy. Hypertension can lead to alterations in the blood vessels supplying the placenta, increasing the risk of detachment.

The other are known risk factors but less common.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

Correct Answer is D

Explanation

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is caring for a newborn. Exhibits Complete the diagram by specifying: The potential condition the newborn is most likely experiencing. Two actions the nurse should take to address that condition. Two parameters the nurse should monitor to assess the newborn's progress.

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

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?

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?