A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun.
A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

Sustained uterine hypertonicity.

Strong uterine contractions every 3-4 minutes.

Bile-colored vomitus.

Fetal heart rate acceleration with fetal activity.

Answer and Explanation

The Correct Answer is A

This means that the uterus is constantly contracted and does not relax between contractions. This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae. Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.

Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.

Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.

Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby. Placental abruption can cause fetal distress and a decrease in fetal heart rate.

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Correct Answer is C

Explanation

The correct answer is choice C. Assess the client’s blood pressure.Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.

Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).

Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.

Pain is not a contraindication for this medication and does not affect its effectiveness.

Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.

Respiratory rate is not affected by this medication and does not indicate any adverse effects.

Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.

Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.

A. Increased Babinski reflex. B. Diarrhea. C. Tetany. D. Decreased respirations.

Correct Answer is D

Explanation

The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.

This is a serious side effect that needs to be monitored closely by the nurse.

Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.

The Babinski reflex is a normal response in infants, but abnormal in adults.

It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.

Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.

Choice C is wrong because tetany is not a side effect of magnesium sulfate.

Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.

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A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with postpartum hemorrhage. The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

Correct Answer is C

Explanation

A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

Correct Answer is D

Explanation

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A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun.
A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?