A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and reports continuous abdominal pain and dark red vaginal bleedinG. The tocodynamometer shows low amplitude high frequency uterine activity. The nurse should identify that the client is likely experiencing which of the following complications? (Select onE.:

Prolapsed cord

Premature rupture of membranes

Abruptio placentae

Placenta previa

Answer and Explanation

The Correct Answer is C

Choice A: Prolapsed cord is not a likely complication, as it is characterized by a sudden onset of severe variable decelerations of the fetal heart rate and a visible or palpable cord in the vaginA. The nurse should identify a prolapsed cord as a medical emergency and perform immediate interventions to relieve the cord compression and deliver the fetus.

Choice B: Premature rupture of membranes is not a likely complication, as it is characterized by a gush or a trickle of clear or yellowish fluid from the vagina and a positive nitrazine or fern test. The nurse should identify premature rupture of membranes as a risk factor for infection and monitor the fetal heart rate and the maternal temperaturE.

Choice C: Abruptio placentae is a likely complication, as it is characterized by continuous abdominal pain and dark red vaginal bleeding and a board-like abdomen. The nurse should identify abruptio placentae as a life-threatening condition that involves the premature separation of the placenta from the uterine wall and can cause fetal distress and maternal hemorrhagE.

Choice D: Placenta previa is not a likely complication, as it is characterized by painless bright red vaginal bleeding and a soft and relaxed uterus. The nurse should identify placenta previa as a condition that involves the abnormal implantation of the placenta near or over the cervical os and can cause fetal hypoxia and maternal hemorrhagE.

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Correct Answer is C

Explanation

A. "You are far enough along that your baby will be just finE." This is not a good response because it is dismissive of the client's concerns and does not provide any factual information or reassurancE. The nurse should not make false promises or minimize the client's feelings.

B. "Everyone worries about their baby while they are in labor." This is not a good response because it is generalizing and does not address the client's specific situation. The nurse should not compare the client to others or imply that their worries are normal or insignificant.

D. "We have a neonatal unit here equipped to handle emergencies." This is not a good response because it implies that there is a high risk of complications and may increase the client's anxiety. The nurse should not focus on negative outcomes or scare the client with unnecessary information.

A. Apply lotion to the newborn's skin twice per day. B. Maintain the newborn in a prone position. C. Encourage the newborn to breastfeed every 2 hours. D. Monitor the newborn's blood glucose level hourly.

Correct Answer is ["C","D"]

Explanation

Choice A: Applying lotion to the newborn's skin twice per day is not an appropriate action, as it can interfere with the effectiveness of phototherapy and increase the risk of skin irritation and infection. The nurse should avoid using any creams, oils, or lotions on the newborn's skin during phototherapy.

Choice B: Maintaining the newborn in a prone position is not an appropriate action, as it can increase the risk of suffocation and aspiration. The nurse should position the newborn on the back or the side and rotate the position every 2 to 4 hours to expose different areas of the skin to the light.

Choice C: Encouraging the newborn to breastfeed every 2 hours is an appropriate action, as it helps prevent dehydration and maintain adequate nutrition and hydration. The nurse should also monitor the newborn's weight, intake, and output and supplement with formula or intravenous fluids if needeD.

Choice D: Monitoring the newborn's blood glucose level hourly is an appropriate action, as it helps detect and treat hypoglycemia, which can occur due to increased metabolic rate and decreased caloric intakE. The nurse should also monitor the newborn's bilirubin level, hematocrit, and electrolytes and report any abnormal findings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan? (Select all that apply):

Correct Answer is ["C","D"]

Explanation

You are assuming the care of a patient admitted for a fetal demise at 30 weeks gestation. Which is the most therapeutic response to the patient? (Select onE.:

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Your patient is receiving magnesium sulfate for neuroprotection and preterm labor at 1 gram/hour. The most concerning vital sign below is:

The baby's head is delivered at 0900. The shoulders are not delivered and you notice a turtle sign. Interventions to relieve a dystocia include (Select all that apply):

A nurse is assisting in the care of a newborn immediately following birtH. The nurse notes mucus bubbling out of the newborn's mouth and nosE. Which of the following actions should the nurse take first? (Select onE.:

A nurse is assisting with the admission of a client who is Hispanic to the labor and delivery unit. Which of the following practices should the nurse anticipate while caring for this client? (Select onE.:

A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following? (Select onE.:

A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply):