22. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?
1. Disseminated intravascular coagulation
2. Chronic hypertension
3. Infection
4. Hemorrhage
= Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
23. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client’s hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following?
1.loud mouth
2. Low self-esteem
3.Hemorrhage
4. Postpartum infections
24. During the period of induction of labor, a client should be observed carefully for signs of:
1.Severe pain
2.Uterine tetany
3. Hypoglycemia
4. Umbilical cord prolapse
= Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
25. Nurse Divina is aware that the following would be an inappropriate indication of placental detachment?
1.An abrupt lengthening of the cord
2. An increase in the number of contractions
3. Relaxation of the uterus
4. Increased vaginal bleeding
= Relaxation isn’t an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.
26. Which of the following complications can be potentially life threatening and can occur in a client receiving a tocolytic agent?
1. diabetic ketoacidosis
2. hyperemesis gravidarum
3. pulmonary edema
4. sickle cell anemia
= Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema.Clients who dont have diabetes dont need to be observed for diabetic ketoacidosis.Hyperemesis gravidium doesnt result from tocolytic use.
Sickle cell anemia is an inherited genetic condition and doesnt develop spontaneously
27. A 20- year-old patient is in the sccond stage of labor and complains of abdominal pain between contractions. What is the most likely diagnosis?
1. vasa pevia
2. abruptio placentae
3. breech presentation
4. posterior presentation
28. Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child’s history, the nurse considers which information to be most important?
1. A fever that started 3 days ago
2. Lack of interest in food
3. A recent episode of pharyngitis
4. Vomiting for 2 days
= A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.
29.A primiparous client at 18 weeks gestation had an ultrasound examination done which showed the mean I will hare to hate a cesarean section which of the following responses by the nurse would be most accurate
1. “If a first baby is breech, it must always be delivered by cesarean section.”
2. “The baby will have more room to turn as your delivery date nears.”
3. “You can probably deliver normally, most babies are born breech.”
4. “Many babies are breech at this stage of pregnancy, most turn by term.
30. A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?
1. Preparatory phase
2. Latent phase
3. Active phase
4. Transition phase
= Cervical dilation occurs more rapidly during the active phase than any of the previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7 cm. The preparatory, or latent, phase begins with the onset of regular uterine contractions and ends when rapid cervical dilation begins. Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.
31. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?
1. Absence of abdominal pain
2. A soft abdomen
3. Uterine tenderness/pain
4. Painless, bright red vaginal bleeding
= In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and