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.

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Correct Answer is D

Explanation

A. Incorrect. Periodic tingling of fingers is not typically considered a sign of a serious prenatal complication. It can be related to normal pregnancy changes such as carpal tunnel syndrome.

B. Incorrect. The absence of clonus is not indicative of a complication. Clonus, or the lack thereof, is a normal finding in the absence of significant neurological issues.

C. Incorrect. Leg cramps are a common issue during pregnancy and usually not a sign of a severe complication.

D. Correct. Blurred vision can be a sign of preeclampsia or other significant prenatal complications, and should be evaluated further to ensure proper management and safety for both the mother and fetus.

A. Respiratory rate 11/min B. Deep tendon reflexes 2+ C. Urine output 30 mL/hr D. Blood pressure 100/62 mm Hg

Correct Answer is A

Explanation

A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.

B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.

C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.

D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?

Correct Answer is D

Explanation

A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for administration of this medication?

A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?

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 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 assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?

A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?

A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?