“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”

“Vaginal bleeding.”.

“Fetal heart rate of 174 bpm.”.

“Fundal height of 33 cm.”.

“Abdomen soft on palpation and without tenderness.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.

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Correct Answer is A

Explanation

Choice A rationale
Decreased extremity edema is a positive sign in a client with deep vein thrombosis (DVT) 48 hours postpartum. DVT is a blood clot that forms in a vein deep in the body, often in the lower leg or thigh. Edema, or swelling, is a common symptom. A decrease in edema may indicate that the condition is improving.
Choice B rationale
Redness in the extremity is not a positive sign in a client with DVT1112. Redness can indicate inflammation or infection, which could suggest a worsening of the condition.
Choice C rationale
Leukocytosis, or an increase in the number of white blood cells, is not a positive sign in a client with DVT1112. It can indicate an infection or inflammation, which could suggest a worsening of the condition.
Choice D rationale
Tachycardia, or a fast heart rate, is not a positive sign in a client with DVT1112. It can indicate a response to decreased oxygen levels in the blood, which could suggest a worsening of the condition.

A. Apply oxygen at 2 L/min via nasal cannula. B. Massage the client’s fundus. C. Turn the client to a side-lying position. D. Assist the client to empty their bladder.

Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula may be beneficial for a client experiencing hypotension following the administration of epidural anesthesia, but it is not the primary action a nurse should take.
Choice B rationale
Massaging the client’s fundus is not an appropriate action for a nurse to take when a client is hypotensive following the administration of epidural anesthesia.
Choice C rationale
Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
Choice D rationale
Assisting the client to empty their bladder may be beneficial in certain circumstances, but it is not the primary action a nurse should take when a client is hypotensive following the administration of epidural anesthesia.

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“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?

Correct Answer is A

Explanation

A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

A nurse is educating the parents of a newborn about the Plastibell circumcision technique. Which piece of information should the nurse include in the teaching?

A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following Questions should the nurse ask to assess the client’s dietary intake?

A nurse is caring for a client who is postpartum following a vaginal birth. Which analgesic medication should the nurse plan to administer and document in the client’s medical record?

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?