A pregnant woman initiated prenatal care at 12 weeks’ gestation.

At that time, her hemoglobin and hematocrit were 13 gm/dL and 36%, respectively.

Review her following prenatal labs at 28 weeks’ gestation: Hgb: 10.5 gm/dL Hct: 32% Blood type: B GBS: Positive Based on this data, what is the appropriate nursing action?

Administer a Rhogam injection.

Teach about iron-rich foods in her diet.

Notify the midwife to start PO antibiotics to treat the GBS.

Teach about avoiding exposure to rubella.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering a Rhogam injection is not indicated because the patient is Rh-positive (blood type B) and Rhogam is for Rh-negative individuals to prevent sensitization.
Choice B rationale
Teaching about iron-rich foods is appropriate, given her hemoglobin level of 10.5 gm/dL and hematocrit of 32%, indicating mild anemia; iron-rich foods help increase hemoglobin.
Choice C rationale
Starting PO antibiotics for GBS is unnecessary at this stage; antibiotics are administered during labor to prevent neonatal infection, not during prenatal care.
Choice D rationale
Avoiding exposure to rubella is important, but there is no indication in her current prenatal labs that she needs immediate teaching about this infection.

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Correct Answer is C

Explanation

Choice A rationale
Limited perception of bladder fullness can occur with epidural anesthesia, but it is not the most common or harmful complication. Patients should be monitored for urinary retention.
Choice B rationale
Severe afterbirth headache, or post-dural puncture headache, can result from epidural complications, but it is less common than hypotension.
Choice C rationale
Hypotension is the most common and potentially harmful complication of epidural anesthesia. It occurs due to sympathetic nerve blockade, leading to vasodilation and decreased cardiac output. Normal blood pressure ranges: systolic 90-120 mmHg, diastolic 60-80 mmHg.
Choice D rationale
Increased respiratory rate is not a common complication of epidural anesthesia. It is more likely related to anxiety or other factors and should be monitored accordingly.

A. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines. B. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. C. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines. D. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.

Correct Answer is B

Explanation

Choice A rationale
The cervix is measured in dilation, not effacement, in centimeters. Effacement is expressed in percentage, indicating the thinning of the cervix.
Choice B rationale
The cervix is 3 cm dilated, 30% effaced, and the presenting part is 2 cm above the ischial spines. This assessment provides a clear status of labor progress.
Choice C rationale
The presenting part being below the ischial spines would be recorded with a positive station, indicating descent into the pelvis, unlike this assessment.
Choice D rationale
The cervix is assessed for dilation in centimeters and effacement in percentage, with station indicating the relationship to the ischial spines.

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Naxlex Comprehensive Predictor Exams

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:

Correct Answer is C

Explanation

The nurse has received a report regarding her patient in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and -2. The nurse’s interpretation of this assessment is that:

Correct Answer is B

Explanation

The factors that affect the process of labor and birth, known commonly as the five Ps, include all except:

A pregnant client at 22 weeks’ gestation has a hematocrit of 35%. Pre-pregnancy hematocrit was 40%. Which of the following statements by the nurse best explains this change?

The nurse caring for the laboring woman should know that meconium is produced by:

The nurse caring for the laboring woman should understand that early decelerations are caused by:

When administering Pitocin, you should start at a low dose and work your way up slowly to a dose that provides the best contraction rate.

After the nurse completes nutritional counseling for a pregnant woman, she asks the client to repeat the instructions to assess the client’s understanding. Which statement indicates that the client understands the role of protein in her pregnancy?

Which factor would alert the nurse that a pregnant woman is at risk for the development of toxoplasmosis?