A client with a history of three spontaneous abortions is now at 16 weeks' gestation and expresses a concern about remaining at home during pregnancy.
Which query will elicit a response most helpful to the nurse developing the client's plan of care?

Are you aware of how a healthy lifestyle affects a pregnancy?

Do you know the causes related to the spontaneous abortions?

What are the characteristics of an impending spontaneous abortion?

What have you been told about the status of your pregnancy?

Answer and Explanation

The Correct Answer is D

Choice A rationale

This question focuses on general health knowledge, which, while important, doesn't directly address the client's current psychological distress and anxiety related to her history of recurrent pregnancy loss and current concern about being at home. The plan of care needs to first establish the client's understanding and perception of her current pregnancy status.

Choice B rationale

Understanding the etiology of previous spontaneous abortions, such as chromosomal abnormalities or uterine anomalies, is valuable for medical management but may not be known and doesn't immediately address the client's current, expressed anxiety about remaining at home. The most helpful response first assesses the client's current belief system regarding this specific pregnancy.

Choice C rationale

Asking about signs of an impending spontaneous abortion focuses on potential complications, which could increase the client's anxiety. While patient education is crucial, the initial priority is to understand the client's current knowledge and perception of her present pregnancy status, which is key to tailoring support.

Choice D rationale

This question is most helpful because it assesses the client's current understanding of her pregnancy's stability, which directly relates to her expressed concern about staying home. A clear understanding of the fetal and maternal status provides the necessary foundation for the nurse to plan appropriate supportive care and education.

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Free Nursing Study Resources

Correct Answer is ["100"]

Explanation

Step 1 is: Calculate the volume of the magnesium sulfate solution that contains the ordered dose. 500 mL÷30 g = 16.666. mL/g. 6 g/hr×16.666. mL/g = 100 mL/hr. The final calculated answer is 100 mL/hr.

A. Increase intravenous fluid replacement. B. Insert an indwelling urinary catheter. C. Monitor deep tendon reflexes. D. Initiate a peri-pad count. E. Perform a fundal massage. F. Administer tocolytic therapy.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Uterine atony is the leading cause of postpartum hemorrhage, resulting in significant blood loss and hypovolemia. Increasing intravenous fluid replacement with crystalloid solutions (e.g., normal saline or lactated Ringer's) is critical to restoring circulating blood volume, maintaining hemodynamic stability, and preventing hypovolemic shock.

Choice B rationale

A full bladder can displace the uterus and impede its ability to contract effectively, contributing to or worsening uterine atony. Inserting an indwelling urinary catheter (Foley catheter) ensures continuous bladder drainage and decompression, allowing the uterus to move into its proper place and contract more effectively.

Choice C rationale

Monitoring deep tendon reflexes (DTRs) is primarily an assessment for magnesium sulfate toxicity in clients being treated for preeclampsia or eclampsia. While relevant in those specific conditions, it is not a direct intervention for managing the immediate effects or cause of postpartum hemorrhage due to uterine atony. Normal DTR response is 2+.

Choice D rationale

Quantifying blood loss is essential for determining the severity of the hemorrhage and the efficacy of interventions. Initiating a peri-pad count and accurately weighing the pads provides a reliable, though often underestimated, measure of blood loss, guiding the need for additional fluids, blood products, or uterotonic medications.

Choice E rationale

Uterine atony is a failure of the uterine muscle to contract and compress the blood vessels at the placental site. Performing a fundal massage stimulates the myometrium to contract, thereby physically compressing the vessels and activating the natural physiological mechanisms to stop the bleeding; this is a primary, initial intervention.

Choice F rationale

Tocolytic therapy, such as terbutaline or nifedipine, works by relaxing the uterine muscle, which is used to stop preterm labor. In the context of uterine atony, the goal is to contract the uterus, so administering tocolytic therapy would be contraindicated as it would worsen the atony and accelerate blood loss.

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A client with a history of three spontaneous abortions is now at 16 weeks' gestation and expresses a concern about remaining at home during pregnancy. Which query will elicit a response most helpful to the nurse developing the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

The nurse is caring for a postpartum client with suspected uterine atony. Which interventions would the nurse initiate to improve the patient's status? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A pregnant client is receiving magnesium sulfate to prevent eclampsia via a continuous intravenous infusion. Hourly assessments are recorded. Which assessment findings lead the nurse to stop the infusion immediately? Select all that apply.

While assessing a client during the fourth stage of labor, the nurse notes that the perineal pad is soaked with approximately 75 mL of lochia rubra. Which nursing action is the priority?

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A nurse is caring for a postpartum client who is a G2 P2002, delivered a 4200 gram neonate vaginally after 4 hours of labor. Based on the client's delivery information, what postpartum complication is the client at risk for?

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A woman who underwent a primary cesarean birth for a breech presentation states that her neonate seems to have so much more mucus than her first baby. Concerned, she asks why this has happened. What is the best response by the nurse?

A client with a history of three spontaneous abortions is now at 16 weeks' gestation and expresses a concern about remaining at home during pregnancy.
Which query will elicit a response most helpful to the nurse developing the client's plan of care?