A nurse is reviewing the electronic medical record (EMR) of a client who is in the labor and delivery triage unit. Nurses' Notes 1700: Client is 38-weeks of gestation and reports recent onset of uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 1 hour prior to arrival. Client reports taking prescribed prenatal vitamins and methyldopa that is prescribed orally twice per day. 1730: Physical Exam: Past Medical History: Gestational hypertension General: anxious Cardiovascular: S1, S2, no murmur Respiratory: bilateral lung sounds clear Abdomen: hard and rigid, uterine hypertonicity, tenderness upon palpation to left upper quadrant. Toco and ultrasound transducer applied. FHR 140/min. Genitourinary: Mild amount of dark red blood noted on the perineal pad For each of the client's findings from the EMR, click to specify if the finding is consistent with placenta previa or abruptio placenta. Each finding may support more than 1 condition. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Uterine tone

Vaginal bleeding characteristics

Pain rate

Client weeks of gestation

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A,B"}}

•   Uterine tone
o   Placenta previa: Not typically associated with abnormal uterine tone.
o   Abruptio placenta: Associated with hard and rigid abdomen, uterine hypertonicity, and tenderness.
•   Vaginal bleeding characteristics
o   Placenta previa: Typically characterized by bright red, painless vaginal bleeding.
o   Abruptio placenta: Often associated with dark red, painful vaginal bleeding.
•   Pain rate
o   Placenta previa: Usually presents with minimal or no pain.
o   Abruptio placenta: Associated with sudden, severe abdominal pain and tenderness.
•   Client weeks of gestation
o   Placenta previa: Commonly diagnosed later in pregnancy, around 30 weeks or later.
o   Abruptio placenta: Can occur at any point after 20 weeks of gestation, but often seen closer to term.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Peanut butter sandwich: Incorrect. Peanut butter contains phenylalanine, an amino acid that people with phenylketonuria (PKU) must limit in their diet. Foods high in phenylalanine should be avoided to prevent complications.

B. Sliced apples: Correct. Sliced apples are low in phenylalanine and safe for individuals with PKU. Fruits are generally recommended for PKU patients as they provide essential nutrients without significant amounts of phenylalanine.

C. Glass of skim milk: Incorrect. Milk, including skim milk, contains phenylalanine, which should be limited or avoided by individuals with PKU. They need to consume specially formulated low-phenylalanine products.

D. Scrambled egg: Incorrect. Eggs are high in phenylalanine and should be avoided by individuals with PKU. They need to choose low-protein alternatives that do not contribute to their phenylalanine levels.

A. "I will check the identification badge of anyone who removes my baby from our room." B. "I should include a photo of my baby in any public birth announcements to social media." C. "I will allow my baby to sleep on the bed in my room when I am in the shower." D. "I should expect the nurses to carry my baby in their arms to the nursery."

Correct Answer is A

Explanation

A. Correct. Checking the identification badge of anyone who removes the baby from the room is an essential safety measure to ensure the baby is only handled by authorized personnel.

B. Incorrect. Sharing a photo of the baby on social media can pose security risks and is not recommended for newborn safety.

C. Incorrect. Allowing the baby to sleep unattended on the bed is unsafe due to the risk of falling or suffocation. The baby should always be in a safe sleep environment.

D. Incorrect. Nurses should follow protocols for transporting babies, which typically involve using a crib or bassinet rather than carrying the baby in their arms, to ensure safety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who gave birth 1 week ago. The client states, "I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason." The nurse should identify that the client is experiencing which of the following emotional responses to birth?

A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?

A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 8 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase their intake during the first trimester of pregnancy?

A nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?

A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?