A client at 28 weeks of gestation presents with bleeding from the vagina.

Which assessment finding should the nurse prioritize?

Regular uterine contractions occurring every 15 minutes

Low back pain and pelvic pressure

Change in vaginal discharge

Rupture of membranes

Answer and Explanation

The Correct Answer is A

Regular uterine contractions occurring every 15 minutes.

This finding suggests that the client may have placental abruption, which is a serious complication that requires immediate medical attention. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause heavy bleeding, pain, and fetal distress.

Choice B is wrong because low back pain and pelvic pressure are common symptoms of preterm labor, which is not as urgent as placental abruption.

Choice C is wrong because a change in vaginal discharge is not a specific sign of any complication and may be normal in pregnancy.

Choice D is wrong because rupture of membranes is not a priority finding in this case, unless it is associated with infection or cord prolapse.

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Correct Answer is A

Explanation

Leukocoria (white pupils) is a symptom of retinopathy of prematurity (ROP), an eye disease that can happen in premature babies.ROP happens when abnormal blood vessels grow on the retina, the light-sensitive layer of tissue in the back of the eye.

Choice B is wrong because strabismus (crossed eyes) is not a symptom of ROP, but a possible complication that can occur later in life.

Choice C is wrong because nystagmus (involuntary eye movements) is not a symptom of ROP, but another possible complication that can occur later in life.

Choice D is wrong because it includes choices B and C, which are incorrect.

Normal ranges for gestational age and birth weight are 38 to 42 weeks and 5.5 to 10 pounds, respectively.Babies born before 31 weeks or weighing less than 3 pounds are at risk for ROP.

A. Hypotension B. Tachycardia C. Hyperglycemia D. Hypokalemia

Correct Answer is B

Explanation

Tachycardia.

Terbutaline is a medication that can be used to stop or delay preterm labor by relaxing the uterine muscles.However, it can also cause serious side effects for both the mother and the baby.One of the most common side effects of terbutaline is tachycardia, which means a fast or irregular heartbeat.This can lead to chest pain, palpitations, shortness of breath, and even cardiac arrhythmias or ischemia.

Therefore, the nurse should monitor the mother’s heart rate and rhythm closely when administering terbutaline.

Choice A is wrong because terbutaline does not cause hypotension, which means low blood pressure.In fact, terbutaline can increase blood pressure by constricting blood vessels.

Choice C is wrong because terbutaline does not cause hyperglycemia, which means high blood sugar.However, terbutaline can interfere with insulin secretion and glucose metabolism in some cases, especially in diabetic mothers.

Therefore, the nurse should monitor the mother’s blood sugar levels when administering terbutaline.

Choice D is wrong because terbutaline does not cause hypokalemia, which means low potassium levels in the blood.However, terbutaline can cause a temporary increase in potassium levels in the baby, which can affect the baby’s heart function.

Therefore, the nurse should monitor the baby’s heart rate and rhythm when administering terbutaline.

Normal ranges for heart rate are 60 to 100 beats per minute for adults and 120 to 160 beats per minute for fetuses.

Normal ranges for blood pressure aretypically between 90/60 mmHg and 120/80 mmHg.

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A client at 28 weeks of gestation presents with bleeding from the vagina. Which assessment finding should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a pre-term newborn who has retinopathy of prematurity (ROP). Which of the following manifestations should the nurse expect to observe?

Correct Answer is A

Explanation

A nurse is administering terbutaline to a client who is at 31 weeks of gestation and has pre-term labor. Which of the following findings should the nurse monitor as an adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results of a pre-term newborn who was born at 32 weeks of gestation. Which of the following values indicates a potential complication of necrotizing enterocolitis (NEC)?

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A nurse is teaching a client who is pregnant about the risk factors for pre-term labor. Which of the following statements by the client indicates a need for further teaching?

A nurse is providing discharge teaching to a client who delivered a pre-term newborn at 34 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing a pre-term newborn who was born at 28 weeks of gestation. Which of the following findings indicates a possible diagnosis of respiratory distress syndrome (RDS)?

A client at 28 weeks of gestation presents with bleeding from the vagina.

Which assessment finding should the nurse prioritize?