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NURSING 240 QUESTIONS AND CORRECT ANSWERS WITH EXPLANATIONS
- A home care nurse is innstructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: A. Eat foods high in calories and fat B. Lie down for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? E. Clonus is present. Incorrect F. Magnesium level is 10 mg/dL. G. Deep tendon reflexes are absent. H. The client experiences diuresis within 24 to 48 hours. Correct Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 2+ but should not be absent. A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: I. Vitamin K J. Protamine sulfate Incorrect K. Calcium gluconate Correct L. Naloxone hydrochloride Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of
hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid-induced respiratory depression. A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein. A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: Q. Avoid the use of shampoo on the infant’s scalp Incorrect R. Apply oil to the affected area on the infant’s scalp Correct S. Wash the infant’s scalp daily, using only tepid water T. Shampoo the infant’s scalp, avoiding the anterior fontanel area Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation. A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: U. Notifies the registered nurse V. Documents the findings W. Instructs the client to take several deep breaths Correct X. Administers 100% oxygen by way of face mask Incorrect Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the registered nurse. If the deep breaths fail to increase the oxygen saturation level, the registered nurse is notified and may prescribe oxygen.
Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the registered nurse. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids. A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: AK. Has the client void before the uterine assessment AL. Tells the woman to bear down during fundal message AM. Simultaneously provides pressure over the lower uterine segment Correct AN. Asks the client to take slow, deep breaths during fundal assessment Incorrect Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the first action and the number 5 to the last. Incorrect A. Assessing the client’s fundus B. Checking the client’s vital signs C. Changing the client’s peripads D. Contacting the physician E. Documenting the findings The correct order is: F. Assessing the client’s fundus G. Checking the client’s vital signs H. Contacting the physician I. Changing the client’s peripads J. Documenting the findings Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client’s fundus. Once it has been determined that the bleeding is not the result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has compromised the client’s condition. Next the nurse would contact the physician and report the bleeding, fundal height and condition, and vital signs. After contacting the physician the nurse would attend to the
NURSING 240 QUESTIONS AND CORRECT ANSWERS WITH EXPLANATIONS
client’s comfort needs, including, in this case, frequent changes of peripads. The nurse would document the findings once assessment and implementation had been completed and the client’s condition was considered stable. A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: A. Normal B. Reactive Incorrect C. Nonreactive Correct D. Inconclusive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? E. “I know how you feel.” F. “This must be hard for you.” Correct G. “Now you have an angel in heaven.” H. “You’re young. You can have other children.” Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings. A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? I. Water and pretzels J. Low-fat cheese omelet Incorrect K. Nachos and fried chicken L. Apple and whole-grain toast Correct Rationale: The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation
NURSING 240 QUESTIONS AND CORRECT ANSWERS WITH EXPLANATIONS
Y. Count the fetal heart rate for 1 minute Rationale: In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman’s comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones. Counting the fetal heart rate is not associated with Leopold maneuvers. A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time? Z. Lochia alba AA. Lochial clots Incorrect AB. Lochia serosa AC. Dark-red lochia rubra Correct Rationale: When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14. A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: AD. Take a cool shower just before breastfeeding AE. Avoid breastfeeding during the night time hours to ensure adequate rest AF. Gently massage the breasts during breastfeeding to help empty the breasts Correct AG. Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown. When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure?
AH. 4 days after delivery Incorrect AI. The day after delivery AJ. Immediately after delivery Correct AK. When the client’s bladder is full Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day. A nurse assists the primary healthcare provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy? Assign the number 1 to the first action and the number 5 to the last action. Incorrect A. Determining the fetal heart rate B. Taking the client’s temperature, pulse, and blood pressure C. Noting the quantity, color, and odor of the amniotic fluid D. Replacing soiled underpads from beneath the client’s buttocks E. Planning evaluation of the client for signs and symptoms of infection The correct order is: F. Determining the fetal heart rate G. Noting the quantity, color, and odor of the amniotic fluid H. Taking the client’s temperature, pulse, and blood pressure I. Replacing soiled underpads from beneath the client’s buttocks J. Planning evaluation of the client for signs and symptoms of infection Rationale: After amniotomy, the fetal heart rate is assessed for at least 1 full minute for changes associated with prolapse or compression of the umbilical cord and the characteristics of the fluid are noted as an indicator of fetal risk. After the fluid has been assessed, the next concern is evaluation of the maternal vital signs. The client’s comfort (i.e., the soiled underpads) is considered next. With the ruptured membranes comes an increased risk for maternal infection. For this reason, the client is frequently assessed for signs and symptoms of infection throughout the course of labor. A licensed practical nurse (LPN) is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the LPN to contact the registered nurse? A. Maternal fatigue B. Clear amniotic fluid C. Strong-smelling amniotic fluid Correct D. A fetal heart rate of 140 beats/min
damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth. A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: Q. The infant must be isolated from the mother after birth R. Maternal medication will not be started until the baby is born S. The infant will require medication therapy immediately after birth T. The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months Correct Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B 6 ) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital. A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is: Z. Supine, on the right side
AA. Lying down with the arm in a horizontal position at heart level AB. In a sitting position with the arm in a horizontal position at heart level Correct Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client sitting position and the arm supported in a horizontal position at heart level. Supine on the right or left side and lying down with the arm in a horizontal position at heart level are both incorrect and could cause physiological stress that would affect the blood pressure. A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? AC. 20 cm Correct AD. 28 cm AE. 32 cm AF. 40 cm Rationale: During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman’s bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present. A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: AG. Indicate that labor has started AH. Must be reported to the physician AI. Are a common occurrence of pregnancy Correct AJ. Necessitate bed rest for the remainder of the pregnancy Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions are a normal finding experienced by many pregnant women during pregnancy, the other options represent inaccurate assumptions and an unnecessary intervention. A nurse is assisting a physician
After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant: AW. Requires vigorous resuscitation AX. Is adjusting well to extrauterine life Correct AY. Requires some resuscitative intervention AZ. Is having difficulty adjusting to extrauterine life Rationale: One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. A score of 7 to 10 indicates that the infant should have no difficulty adjusting to extrauterine life. A score of 4 to 6 indicates moderate difficulty that may require some resuscitative intervention. A score of 0 to 3 indicates severe distress and the need for vigorous resuscitation. A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: BA. Walk half a mile 3 times a week BB. Drink at least 2 quarts of fluid per day BC. Perform Kegel exercises in 10 repetitions, three times per day Correct BD. Perform pelvic tilt exercises in 10 repetitions, three times per day Rationale: Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is beneficial during pregnancy and afterward. Walking is a general healthy measure but does not specifically strengthen the pelvic floor. Fluid intake is an indicator of hydration, which is important for normal physiological function. Pelvic tilt exercises ease backache. A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis? BE. Maintaining strict asepsis BF. Monitoring the maternal vital signs BG. Administering oxygen as prescribed Correct BH. Placing a wedge under the client’s hip Rationale: Oxygen is administered continuously during labor to the client with sickle cell anemia to help ensure adequate oxygenation and prevent sickling. Maintaining asepsis, monitoring vital signs, and placing a wedge under the hip are interventions required of all clients, with or without sickle cell anemia. Although they are appropriate nursing interventions, they are not used to prevent sickling crisis.
A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which of the following findings does the nurse tell the mother is an indicator of infection? BI. A darkened, drying cord BJ. Edema at the base of the cord Correct BK. A brownish-black cord with pinkness around the base
BW. “I need to report signs of infection to my physician.” BX. “My insulin requirements may change while I’m pregnant.” BY. “I’ll come back for a prenatal visit every month during my first trimester.” Correct Rationale: Exercise is necessary for the pregnant diabetic client to help maintain control of her diabetes. Concepts related to the timing of exercise, control of food intake, and insulin around the time of exercise should be reviewed with the client. The prenatal visit schedule for clients with a history of diabetes mellitus is more frequent than the normal prenatal course. In the first and second trimesters, prenatal visits should be scheduled every 1 to 2 weeks. The remaining statements are correct, representing important information for the pregnant client with diabetes mellitus. During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” The appropriate response is: BZ. “Weight loss could hurt your baby.” CA. “Let’s make a list of what you’re eating.” Correct CB. “I’ll have the doctor review your diet history.” CC. “It’s all right to gain weight during pregnancy.” Rationale: It is important for the nurse to obtain additional information from the client. The nurse is using the therapeutic communication tool of validation and clarification to obtain more information about the client’s diet. The other options will block communication. The statement regarding harm to the baby devalues the client and shows disapproval. Informing the physician is avoiding the issue, and telling the client that it is all right to gain weight provides false reassurance. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: CD. Lie down CE. Contact the physician CF. Drink 8 oz of diet soda CG. Check her blood glucose level Correct Rationale: If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL, the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz) of unsweetened fruit juice, a half cup (4 oz) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after intake of the carbohydrate. If the glucose level is still below 60 mg/dL, the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood
glucose is tested once again 15 minutes after intake of the carbohydrate, and the physician is notified immediately if it is still below 60 mg/dL, because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention. A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. CH. The infant has urinated. Correct CI. The infant has passed 1 stool. Correct CJ. Vital signs are documented as normal. Correct CK. The infant has completed one successful feeding. CL. The infant has shown no evidence of jaundice in the first 6 hours of life. Rationale: Criteria for early discharge in the newborn infant include no evidence of significant jaundice in the 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: CM. Preparing to induce labor CN. Turning the client on her left side CO. Preparing the client for a cesarean delivery Correct CP. Continuing to monitor the fetal heart rate pattern Rationale: Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need for cesarean delivery. Induction of labor is not indicated in this case because the client has been in labor for 12 hours without progress and signs of fetal distress are present. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. However, this intervention would be implemented with any client in labor, not specifically with a client experiencing dystocia. Monitoring the fetal heart rate pattern is also appropriate for any client in labor and is not the appropriate nursing action in this situation. Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: CQ. Pulls on the placenta as it enters the vaginal canal CR. Pulls on the umbilical cord as the mother bears down CS. Applies strong traction on the cord when signs of separation occur
lesser priority than reporting the time of last oral intake. Giving acetaminophen (Tylenol) is incorrect because it requires a physician’s prescription. A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: DD. Positions the client on her side Correct DE. Calls the physician to see the client DF. Places a cool washcloth on the client’s forehead DG. Checks the client’s blood pressure, pulse, and respirations Rationale: Supine hypotension may occur during the second and third trimesters when a woman is placed in the lithotomy position, in which the weight of the abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure and a feeling of faintness. Other signs and symptoms include pallor, dizziness, breathlessness, tachycardia, nausea, clammy (damp, cool) skin, and sweating. The nurse would immediately position the woman on her side. Placing a cool washcloth on the client’s forehead or checking the client’s vital signs will not eliminate this problem. The physician must be contacted if the symptoms do not subside, but this would not be the immediate action. A nurse is caring for a client in precipitous labor. In which position does the nurse place the client? DH. DI. DJ. DK. Correct Rationale: Priority nursing care of the woman in precipitous labor includes promotion of fetal oxygenation and maternal comfort. A side-lying (lateral Sims) position enhances placental blood flow and reduces the effects of aortocaval compression. Added benefits of this position are slowing of rapid fetal descent and minimization of perineal tearing. The lateral Sims position also places less stress on the perineum. Because the upper leg is supported, the perineum can be better visualized as well. The other options are not the most optimal positions. A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: DL. Seizures DM. Infection DN. Hemorrhage Correct DO. A vaginal hematoma
Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a low-lying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply. DP. A primipara DQ. A 36- year-old DR. A hypertensive client Correct DS. A pack-a-day smoker Correct DT. A client who exercises regularly Rationale: The cause of abruptio placentae is unknown, but several risk factors have been identified. Maternal use of cocaine, which causes vasoconstriction of the endometrial arteries, is a leading cause. Other risk factors include hypertension, cigarette smoking, abdominal trauma, and a history of previous premature separation of the placenta. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is: DU. Contacting the physician Correct DV. Documenting the findings DW. Continuing to monitor the client DX. Reassuring the client and her partner that labor is progressing normally Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response, but, of the options provided, contacting the physician is the most appropriate. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: DY. The exercises should be delayed for 1 month to allow healing DZ. Performing such exercises in the postpartum period may result in stress urinary incontinence EA. Alternating contraction and relaxation of the muscles of the perineal area should
