Trivia Quiz On Nursing care And Patient Health Safety

1. A nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning?

"Iron supplements will give me diarrhea."

"The iron is needed for the red blood cells."

"Meat does not provide iron and should be avoided."

"My body has all the iron it needs, and I don't need to take supplements."

A nutritional supplement that is commonly needed during pregnancy is iron. Anemia of pregnancy is primarily caused by iron deficiency. Iron supplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal sternum.

Explanation

A nutritional supplement that is commonly needed during pregnancy is iron. Anemia of pregnancy is primarily caused by iron deficiency. Iron supplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal sternum.

2. A nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS). The client asks the nurse if she will be able to breast-feed the infant after delivery. Which response by the nurse is appropriate?

"Breast-feeding is contraindicated."

"Breast-feeding is allowed as long as the mother is taking zidovudine (AZT)"

"Breast-feeding is allowed as long as the infant is not showing signs of human immunodeficiency virus (HIV) infection."

"Breast-feeding is allowed as long as the infant receives an immunization for HIV."

The woman with AIDS will need to know that breast-feeding is contraindicated but that she can provide all other care for her infant. Characteristically, the newborn is asymptomatic at birth, and signs and symptoms usually become obvious during the first year of life. There is not an immunization currently available for HIV.

Explanation

The woman with AIDS will need to know that breast-feeding is contraindicated but that she can provide all other care for her infant. Characteristically, the newborn is asymptomatic at birth, and signs and symptoms usually become obvious during the first year of life. There is not an immunization currently available for HIV.

3. During the intrapartum period, a nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:

Stimulate the labor process

Avoid the necessity of a cesarean delivery

Prevent dehydration and hypoxemia

Eliminate the need for analgesics

A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and administering oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

Explanation

A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and administering oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

4. A licensed practical nurse (LPN) is assisting in gathering information on a client who is scheduled for a cesearean delivery. Which of the following findings would indicate a need to contact the registered nurse (RN)?

Fetal heart rate of 180 beats per minute

White blood cell count of 12,000 /mm3

Maternal pulse rate of 85 beats per minute

Hemoglobin of 11 g/dL

A normal fetal heart rate is 120 to 160 beats per minute. A count of 180 beats per minute could indicate fetal distress and needs to be reported. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 18,000/mm3. During the immediate postpartum period the count may range from 25,000 to 30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The total blood volume increases 30% to 50% by the end of the second trimester. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.

Explanation

A normal fetal heart rate is 120 to 160 beats per minute. A count of 180 beats per minute could indicate fetal distress and needs to be reported. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 18,000/mm3. During the immediate postpartum period the count may range from 25,000 to 30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The total blood volume increases 30% to 50% by the end of the second trimester. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.

5. A pregnant client who is anemic tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?

"You will not have any problems if you follow all the advice the doctor has given you."

"Your baby will need to spend a few days in the neonatal intensive care unit following delivery."

"Don't worry about your baby, complications are rare."

The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options (a) and (c) provide a false reassurance to the client. Option (b) will cause further concern in the client. Option (d) provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

Explanation

The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options (a) and (c) provide a false reassurance to the client. Option (b) will cause further concern in the client. Option (d) provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

6. A nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?

Baseline fetal heart rate

Intensity of contractions

Maternal blood pressure

Frequency of contractions

The nurse should first determine the baseline fetal heart rate. Although options b,c, and d are components of the data collection process, the fetal heart rate is the priority.

Explanation

The nurse should first determine the baseline fetal heart rate. Although options b,c, and d are components of the data collection process, the fetal heart rate is the priority.

7. A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following information will the nurse provide to the client?

"The test is an invasive procedure and requires that you sign an informed consent."

"The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed."

"The fetus is challenged by uterine contractions to obtain the necessary information."

The nonstress test takes about 30 to 40 minutes. The test is termed “nonstress” because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded.

Explanation

The nonstress test takes about 30 to 40 minutes. The test is termed “nonstress” because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded.

8. A nurse is assigned with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client knowing that abruptio placentae is accompanied by which additional finding?

Soft abdomen on palpation

Uterine tenderness on palpation

No complaints of abdominal pain

Lack of uterine irritability or tetanic contractions

Vaginal bleeding in a pregnant client is most often caused by placenta previa or placental abruption. Uterine tenderness accompanies abruptio placentae,especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

Explanation

Vaginal bleeding in a pregnant client is most often caused by placenta previa or placental abruption. Uterine tenderness accompanies abruptio placentae,especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

9. A nurse has assisting in developing a plan of care for the client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which nursing intervention as the highest priority?

Keeping the significant other informed of the progress of labor.

Providing comfort measures.

Monitoring fetal status

Changing the client's position frequently

The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client’s position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status is the priority.

Explanation

The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client’s position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status is the priority.

10. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is:

1 cm above the ischial spines.

1 fingerbreadth below the symphysis pubis.

1 inch below the coccyx

1 inch below the iliac crest

Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.

Explanation

Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.

11. A primigravida's membranes rupture spontaneously. The nurse's first action is to:

Determine the fetal heart rate

Prepare for immediate delivery

Monitor the contraction pattern

Note the amount, color, and odor of the amniotic fluid

When the membranes rupture, the nurse immediately assesses fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Monitoring the contraction pattern and noting the characteristics of amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery.

Explanation

When the membranes rupture, the nurse immediately assesses fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Monitoring the contraction pattern and noting the characteristics of amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery.

12. A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother?

An oral hypoglycemic agent

NPH insulin on a daily basis

A 3-hour glucose tolerance test

A sliding scale Regular insulin dose

A maternal blood glucose measurement is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes. Options (a), (b), and (d) would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented.

Explanation

A maternal blood glucose measurement is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes. Options (a), (b), and (d) would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented.

13. The nurse is monitoring a client in labor whose membranes rupture spontaneously. The initial nursing action is to:

Take the client's blood pressure.

Provide peripads to the client.

Note the amount, color, and odor of the amniotic fluid.

Determine the fetal heart rate.

When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options (a) and (c) are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleansing and changing clothing and may provide peripads to the client, but determining the fetal heart rate is the initial action.

Explanation

When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options (a) and (c) are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleansing and changing clothing and may provide peripads to the client, but determining the fetal heart rate is the initial action.

14. While assisting with the measurement of fundal height, the client at 36 weeks gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely due to:

A full bladder

Emotional instability

Insufficient iron intake

Compression of the vena cava

Compression of the inferior vena cava and the aorta by the uterus may cause supine hypotension syndrome. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem. Options (a),(b),and (c) are not the cause of the problem described in this question.

Explanation

Compression of the inferior vena cava and the aorta by the uterus may cause supine hypotension syndrome. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem. Options (a),(b),and (c) are not the cause of the problem described in this question.

15. A nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?

Placing the mother in a supine position.

Documenting the findings and continuing to monitor the fetal patterns.

Administering oxygen via face mask.

Increasing the rate of the intravenous (IV) oxytocin infusion

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency due to stimulation of contractions caused by the oxytocin. Option (b) would delay necessary treatment.

Explanation

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency due to stimulation of contractions caused by the oxytocin. Option (b) would delay necessary treatment.

16. The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to:

Prepare for an oxytocin infusion.

Keep the client in a side-lying position.

Prepare the client for epidural anesthesia.

Encourage the client to start pushing with the contractions

Priority care of this client includes the promotion of fetal oxygenation. Precipitous labor progresses quickly with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury.

Explanation

Priority care of this client includes the promotion of fetal oxygenation. Precipitous labor progresses quickly with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury.

17. A nurse is collecting data from a pregnant client with a history of heart disease. The nurse is checking for venous congestion. The nurse inspects which of the following areas, knowing that venous congestion is most commonly noted here?

Vulva

Fingers

Around the eyes

Aound the abdomen

Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion.

Explanation

Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion.

18. A client is undergoing an amniocentesis at 16 weeks gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client:

That the bladder must be full during the exam

That the bladder must be empty during the exam.

She will be given RhoGAM because she is Rh positive

Not to eat or drink anything 4 to 6 hours before the exam

Before 20 weeks gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks gestation, the bladder may be emptied minimize the chance of puncturing the placenta or fetus. Rho(D) immune globulin (RhoGAM) is administered to an Rh-negative woman because of the risk of immunization from the fetal blood during the exam. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the exam is an important intervention.

Explanation

Before 20 weeks gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks gestation, the bladder may be emptied minimize the chance of puncturing the placenta or fetus. Rho(D) immune globulin (RhoGAM) is administered to an Rh-negative woman because of the risk of immunization from the fetal blood during the exam. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the exam is an important intervention.

19. A contraction stress test is scheduled for a client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following?

"Uterine contractions are stimulated by Leopold's maneuvers."

"An internal fetal monitor is attached and you will walk on a treadmill until contractions begin."

"The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."

"Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions.

A contraction stress test assesses placental oxygenation and function and determines the fetus' ability to tolerate labor as well as its well-being. The test is performed if the nonstress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother and a 20-30 minute baseline strip is recorded. The uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40-seconds or more during a 10-minute period have occurred. Frequent maternal blood pressure readings are performed and the client is monitored closely while increasing doses of oxytocin are given.

Explanation

A contraction stress test assesses placental oxygenation and function and determines the fetus' ability to tolerate labor as well as its well-being. The test is performed if the nonstress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother and a 20-30 minute baseline strip is recorded. The uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40-seconds or more during a 10-minute period have occurred. Frequent maternal blood pressure readings are performed and the client is monitored closely while increasing doses of oxytocin are given.

20. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which of the following nursing actions is appropriate?

Encourage the client's coach to continue breathing techniques.

Encourage the client to continue pushing with each contraction.

Continue monitoring the fetal heart rate.

Notify the registered nurse (RN).

A normal fetal heart rate is 120 to 160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the RN needs to be notified. Options (a), (b), and (c) are not appropriate nursing actions in this situation.

Explanation

A normal fetal heart rate is 120 to 160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the RN needs to be notified. Options (a), (b), and (c) are not appropriate nursing actions in this situation.

21. A nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which of the following findings is least likely associated with DIC

Swelling of the calf of one leg.

Prolonged clotting times.

Decreased platelet count

Petechiae, oozing from injection sites, and hematuria

DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. Petechiae, oozing from injection sites, and hematuria are associated with the presence of DIC. Swelling and pain in the calf of one leg are more likely associated with thrombophlebitis.

Explanation

DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. Petechiae, oozing from injection sites, and hematuria are associated with the presence of DIC. Swelling and pain in the calf of one leg are more likely associated with thrombophlebitis.

22. During a prenatal visit, a nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states:

"I can eat more sweets now, because I need more calories."

"I need more fat in my diet so that the baby can gain enough weight."

"I need to eat a high-protein, low carbohydrate diet now to control my blood glucose."

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

An increase in calories is needed during pregnancy but concentrated sugars should be avoided because they may cause hyperglycemia. The fat intake should be 20-30% of the total calories. The client with diabetes needs about 50-60% of her caloric intake from carbohydrates and about 12-20% from protein. High fiber foods will control blood glucose levels and prevent constipation.

Explanation

An increase in calories is needed during pregnancy but concentrated sugars should be avoided because they may cause hyperglycemia. The fat intake should be 20-30% of the total calories. The client with diabetes needs about 50-60% of her caloric intake from carbohydrates and about 12-20% from protein. High fiber foods will control blood glucose levels and prevent constipation.

23. A nurse assisting the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:

Monitor the oxytocin (Pitocin) infusion closely.

Provide pain relief measures.

Prepare the client for amniotomy.

Promote ambulation every 30 minutes

Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

Explanation

Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

24. A nurse is monitoring a pregnant client with gestational hypertension who is at risk for pre-eclampsia. The nurse checks the client for which classic signs of preeclampsia? (Select all that apply)

Proteinuria

Hypertension

Low-grade fever

Generalized edema

Increased respiratory rate

The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever and increased respiratory rate are not associated with preeclampsia.

Explanation

The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever and increased respiratory rate are not associated with preeclampsia.

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25. A nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. The appropriate initial intervention in meeting the emotional needs of the client and her spouse is which of the following?

Encourage the client to talk about the dead fetus.

Allow the client and spouse to hold the baby.

Allow the family members to name the baby.

Gather data from the client and spouse about the perception of the event.

The most appropriate initial intervention in planning to meet the emotional needs of the client and her spouse is to gather data about the perception of the event. Although options (a), (b), and (c) are likely to be a component of the plan of care, the initial intervention is to assess the perception of the event.

Explanation

The most appropriate initial intervention in planning to meet the emotional needs of the client and her spouse is to gather data about the perception of the event. Although options (a), (b), and (c) are likely to be a component of the plan of care, the initial intervention is to assess the perception of the event.

26. A nurse is teaching a pregnancy client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the physician. Which of the following would be included on the list? (Select all that apply)

Visual disturbances

Rapid weight gain

Generalized or facial edema

Irregular, painless contractions

Vaginal bleeding

Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal irregular painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, a change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

Explanation

Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal irregular painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, a change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

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27. A nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. (Select all that apply)

Uterine rigidity

Fundal height may be greater than expected for gestational age

Severe abdominal pain

Bright red vaginal bleeding

Soft, relaxed, nontender uterus

Painless bright red vaginal bleeding during the 2nd or 3rd trimester of pregnancy is a sign of placenta previa. The client will have a soft, relaxed, nontender uterus, and the fundal height may be greater than expected for gestational age.

Explanation

Painless bright red vaginal bleeding during the 2nd or 3rd trimester of pregnancy is a sign of placenta previa. The client will have a soft, relaxed, nontender uterus, and the fundal height may be greater than expected for gestational age.

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