You are receiving report from the night shift nurse on a laboring client.
She is 39 weeks gestation, cervical exam is 9cm/100%/0, she has an epidural in place for pain management.
ROM occurred 25 hours ago with a moderate amount of clear fluid.
EFM assessment includes baseline 175bpm, minimal variability, no accelerations, no decelerations.
Vital signs: Blood pressure: 118/84 mmHg.
Respiratory Rate: 16/min.
O2 saturation: 99% on R

Intraamniotic infection.

Pyelonephritis.

Cholestasis of pregnancy.

Placental abruption.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Intraamniotic infection (chorioamnionitis) is suspected due to the combination of prolonged rupture of membranes (25 hours), maternal fever (39.2°C), and fetal tachycardia (baseline of 175 bpm). These are key indicators of infection within the amniotic sac.

Choice B rationale

Pyelonephritis, an infection of the kidneys, is unlikely without the presence of symptoms such as flank pain, dysuria, and significant changes in urinalysis. The primary signs point towards intraamniotic infection.

Choice C rationale

Cholestasis of pregnancy primarily presents with intense itching, especially on the hands and feet, and does not typically involve fever or abnormal fetal heart rates. Thus, it is less likely in this scenario.

Choice D rationale

Placental abruption involves the separation of the placenta from the uterine wall before delivery, often presenting with abdominal pain, vaginal bleeding, and uterine contractions. The absence of these symptoms makes this diagnosis less likely.

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Correct Answer is B

Explanation

Choice A rationale

Abdominal pain with no vaginal bleeding is not typically associated with placenta previa. This condition usually involves painless vaginal bleeding as the placenta covers or is near the cervix, not causing abdominal pain without bleeding.

Choice B rationale

Painless red vaginal bleeding is characteristic of placenta previa. The condition occurs when the placenta covers the cervix, leading to painless bleeding as the cervix begins to thin or dilate.

Choice C rationale

Sharp abdominal pain is not a common sign of placenta previa. This symptom is more indicative of conditions such as placental abruption, where the placenta detaches from the uterine wall.

Choice D rationale

Intermittent abdominal pain following the passage of bloody mucus is not typical of placenta previa. This pattern may suggest labor or other complications, not the classic presentation of painless bleeding seen in placenta previa.

A. Cytomegalovirus. B. Herpes Simplex Virus. C. Hepatitis B. D. Rubella. E. Toxoplasmosis.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Cytomegalovirus (CMV) is a common infection that can be transmitted to the fetus, leading to serious complications such as hearing loss, vision impairment, and developmental delays. It is one of the TORCH infections.

Choice B rationale

Herpes Simplex Virus (HSV) can be transmitted to the baby during delivery, especially if there is an active outbreak. It can cause severe neonatal infections, making it a significant concern during pregnancy.

Choice C rationale

Hepatitis B is not classified under the TORCH infections. While it is a serious concern in pregnancy, it is typically managed through vaccination and other precautions to prevent vertical transmission to the baby.

Choice D rationale

Rubella is part of the TORCH complex and can lead to congenital rubella syndrome, causing serious birth defects such as heart problems, developmental delays, and hearing loss if the mother contracts it during pregnancy.

Choice E rationale

Toxoplasmosis is included in the TORCH infections and can cause severe fetal complications such as brain damage, vision problems, and developmental delays if the mother is infected during pregnancy.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa.Which of the following findings support this diagnosis?

Correct Answer is B

Explanation

A nurse is providing education about TORCH infections to a pregnant client and her partner.The nurse identifies that the client is at risk for which infection?

Correct Answer is ["A","B","D","E"]

Explanation

A laboring client with preeclampsia is prescribed magnesium sulfate 2g/h IVPB. The pharmacy sent the IV to the unit labeled magnesium sulfate 20g/500mL normal saline. To administer the correct dose, the nurse should set the pump to deliver how many milliliters per hour?

A nurse in a provider's office is caring for a client who is at 37 weeks of gestation and at risk for placental abruption.The nurse should recognize that which of the following is a risk factor for abruption?

A nurse in a prenatal clinic is discussing the risks of twin to twin transfusion syndrome with an 18 week pregnant client with monochorionic-monoamniotic (mono-mono) twins.Which of the following statements by the client shows an understanding of the education?

A nurse is caring for a client at 37 weeks gestation with new reports of headache, edema of the face and right upper quadrant abdominal pain.Which of the following diagnostic tests would the nurse anticipate the provider ordering?

A nurse is providing care at a routine visit for a 28-year-old female client who is at 36 weeks of gestation in the clinic. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply.)

A nurse is caring for a client who was recently diagnosed with Hyperemesis Gravidarum.Which of the following medications should the nurse anticipate administering?

A nurse is preparing to administer magnesium sulfate IV to a client who is 30 weeks gestation and experiencing preterm labor.The nurse explains to the client the primary purpose of this medication for her condition is to do which of the following?