A nurse is caring for a 32-year-old female client who is at 28 weeks of gestation,

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition: The client is most likely expeíiencing Placenta píevia. This condition is chaíacteíized by painless, bíight íed vaginal bleeding duíing the thiíd tíimesteí, which matches the client’s symptoms.
Actions:

1. Instíuct the client to maintain bed íest: This can help to píevent fuítheí bleeding.
2. Píepaíe the client foí a possible ultíasound: An ultíasound can help to confiím the diagnosis and assess the placental location and fetal well-being.

Paíameteís to Monitoí:

1. Ïetal heaít íate: Monitoíing the fetal heaít íate can help to assess the baby’s well-being.
2. Hemoglobin and hematocíit levels: These should be monitoíed to assess the client’s blood loss and íisk of anemia.

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Correct Answer is C

Explanation

Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale

A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.

A. Hypotension B. Maternal temperature of 37.4 C (99.4 F) C. Polyuria D. Fetal heart rate 152/min .

Correct Answer is A

Explanation

Choice A rationale
Hypotension is a known adverse effect of epidural analgesia. The epidural can block sympathetic nerve fibers, which can lead to vasodilation and a drop in blood pressure.
Choice B rationale
A maternal temperature of 37.4 C (99.4 F) is within the normal range and is not typically a cause for concern. While epidural analgesia can potentially cause a slight increase in body temperature, a significant fever is not a common side effect.
Choice C rationale

Polyuria, or excessive urination, is not a typical side effect of epidural analgesia. While the epidural can affect nerve signals to the bladder, it does not typically cause the kidneys to produce more urine.
Choice D rationale
A fetal heart rate of 152/min is within the normal range for a fetus (110-160 beats per minute). While epidural analgesia can potentially affect the baby’s heart rate if it causes significant maternal hypotension, a heart rate of 152/min is not indicative of a problem. CytomegalovirusCytomegalovirus Explore

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Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for four patients. For which of the following patients should the nurse notify the provider?

Correct Answer is C

Explanation

A nurse is assessing a client who is in labor and has received epidural analgesia. What findings should the nurse recognize and document as an adverse effect of epidural analgesia?

Correct Answer is A

Explanation

A nurse is admitting a patient to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the patient is 80% effaced and 8 cm dilated.The nurse realizes that the patient is at risk for which of the following conditions?

A nurse is caring for a client who is receiving terbutaline to treat preterm labor. What findings should the nurse identify as a potential adverse effect of this medication?

A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. What responses should the nurse make?

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. What actions should the nurse take?

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

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