Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Initiation of pushing
Initiation of pushing is not an appropriate nursing action, as it can increase the bleeding and the risk of placental separation, which can cause fetal hypoxia, hemorrhage, or shock. Pushing is contraindicated in clients with placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester.
B. Examination to determine cervical status
Examination to determine cervical status is not an appropriate nursing action, as it can cause trauma and perforation of the placenta, which can lead to severe bleeding and infection. Examination is contraindicated in clients with placenta previa, unless it is confirmed by ultrasound that the placenta is not low-lying or covering the cervix.
C. Preparation for cesarean birth
Preparation for cesarean birth is an appropriate nursing action, as it is the preferred mode of delivery for clients with placenta previa, especially if the bleeding is heavy, the fetus is mature, or the fetal distress is present. Cesarean birth can prevent the complications of placenta previa, such as fetal hypoxia, hemorrhage, or shock.
D. A magnesium sulfate infusion
A magnesium sulfate infusion is not an appropriate nursing action, as it is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, which is a hypertensive disorder of pregnancy. Magnesium sulfate is not indicated for clients with placenta previa, unless they also have severe preeclampsia or eclampsia.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam 4. Take the full exam now
Full Explanation
Choice A reason: Initiation of pushing is not an appropriate nursing action, as it can increase the bleeding and the risk of placental separation, which can cause fetal hypoxia, hemorrhage, or shock. Pushing is contraindicated in clients with placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester.
Choice B reason: Examination to determine cervical status is not an appropriate nursing action, as it can cause trauma and perforation of the placenta, which can lead to severe bleeding and infection. Examination is contraindicated in clients with placenta previa, unless it is confirmed by ultrasound that the placenta is not low-lying or covering the cervix.
Choice C reason: Preparation for cesarean birth is an appropriate nursing action, as it is the preferred mode of delivery for clients with placenta previa, especially if the bleeding is heavy, the fetus is mature, or the fetal distress is present. Cesarean birth can prevent the complications of placenta previa, such as fetal hypoxia, hemorrhage, or shock.
Choice D reason: A magnesium sulfate infusion is not an appropriate nursing action, as it is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, which is a hypertensive disorder of pregnancy. Magnesium sulfate is not indicated for clients with placenta previa, unless they also have severe preeclampsia or eclampsia.
Similar Questions
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
A. Preeclampsia
Preeclampsia is not the correct answer, as it is a hypertensive disorder of pregnancy that causes high blood pressure, proteinuria, and edema. Preeclampsia can be a risk factor for abruptio placentae, which is a premature separation of the placenta from the uterine wall, but it is not a complication of it. Preeclampsia does not cause petechiae or bleeding around the IV access site, but rather headaches, blurred vision, or epigastric pain.
B. Anaphylactoid syndrome of pregnancy
Anaphylactoid syndrome of pregnancy is not the correct answer, as it is a rare and fatal condition that occurs when the amniotic fluid enters the maternal circulation and causes an allergic reaction. Anaphylactoid syndrome of pregnancy can occur as a complication of abruptio placentae, but it is not indicated by the petechiae or bleeding around the IV access site. Anaphylactoid syndrome of pregnancy would cause respiratory distress, hypotension, or cardiac arrest.
C. Puerperal infection
Puerperal infection is not the correct answer, as it is a bacterial infection of the reproductive tract that occurs after childbirth. Puerperal infection can occur as a complication of abruptio placentae, but it is not indicated by the petechiae or bleeding around the IV access site. Puerperal infection would cause fever, foul-smelling lochia, or pelvic pain.
D. Disseminated intravascular coagulation
Disseminated intravascular coagulation is the correct answer, as it is a coagulation disorder that causes widespread clotting and bleeding in the body. Disseminated intravascular coagulation can occur as a complication of abruptio placentae, and it is indicated by the petechiae and bleeding around the IV access site. Disseminated intravascular coagulation would also cause a low platelet count, a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), and a low fibrinogen level.
Full Explanation
Choice A reason: Preeclampsia is not the correct answer, as it is a hypertensive disorder of pregnancy that causes high blood pressure, proteinuria, and edema. Preeclampsia can be a risk factor for abruptio placentae, which is a premature separation of the placenta from the uterine wall, but it is not a complication of it. Preeclampsia does not cause petechiae or bleeding around the IV access site, but rather headaches, blurred vision, or epigastric pain.
Choice B reason: Anaphylactoid syndrome of pregnancy is not the correct answer, as it is a rare and fatal condition that occurs when the amniotic fluid enters the maternal circulation and causes an allergic reaction. Anaphylactoid syndrome of pregnancy can occur as a complication of abruptio placentae, but it is not indicated by the petechiae or bleeding around the IV access site. Anaphylactoid syndrome of pregnancy would cause respiratory distress, hypotension, or cardiac arrest.
Choice C reason: Puerperal infection is not the correct answer, as it is a bacterial infection of the reproductive tract that occurs after childbirth. Puerperal infection can occur as a complication of abruptio placentae, but it is not indicated by the petechiae or bleeding around the IV access site. Puerperal infection would cause fever, foul-smelling lochia, or pelvic pain.
Choice D reason: Disseminated intravascular coagulation is the correct answer, as it is a coagulation disorder that causes widespread clotting and bleeding in the body. Disseminated intravascular coagulation can occur as a complication of abruptio placentae, and it is indicated by the petechiae and bleeding around the IV access site. Disseminated intravascular coagulation would also cause a low platelet count, a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), and a low fibrinogen level.
Which assessments are included in the fetal biophysical profile (BPP)? (Select all that apply.)
A. AFI
AFI stands for amniotic fluid index, which is a measurement of the amount of amniotic fluid surrounding the fetus. AFI is an indicator of fetal well-being, as it reflects the fetal urine output and the placental function. A normal AFI is between 5 and 25 cm. A low AFI (< 5 cm) can suggest fetal growth restriction, oligohydramnios, or fetal distress. A high AFI (> 25 cm) can suggest fetal anomalies, polyhydramnios, or maternal diabetes.
B. Fetal heart rate
Fetal heart rate is an assessment of the fetal cardiac activity, which is usually monitored by a non-stress test (NST). Fetal heart rate is an indicator of fetal well-being, as it reflects the fetal oxygenation and the autonomic nervous system. A normal fetal heart rate is between 110 and 160 beats per minute, with moderate variability and accelerations. A non-reactive fetal heart rate (< 2 accelerations in 20 minutes) can suggest fetal hypoxia, acidosis, or distress.
C. Fetal movement
Fetal movement is an assessment of the fetal gross body movements, which are usually counted by the mother or observed by ultrasound. Fetal movement is an indicator of fetal well-being, as it reflects the fetal activity and the central nervous system. A normal fetal movement is at least 3 movements in 30 minutes. A decreased fetal movement (< 3 movements in 2 hours) can suggest fetal sleep, sedation, or distress.
D. Fetal tone
Fetal tone is an assessment of the fetal muscle tone, which is usually observed by ultrasound. Fetal tone is an indicator of fetal well-being, as it reflects the fetal maturity and the neuromuscular system. A normal fetal tone is at least 1 episode of fetal flexion or extension in 30 minutes. An abnormal fetal tone (absent or hypotonic) can suggest fetal immaturity, anomalies, or distress.
E. Placental grade
Placental grade is not an assessment that is included in the fetal biophysical profile (BPP), as it is not a direct measure of fetal well-being, but rather a classification of the placental maturity and calcification. Placental grade is usually evaluated by ultrasound, and it ranges from 0 to 3, with higher grades indicating more calcification and aging. Placental grade can affect the placental function and the fetal growth, but it is not a reliable or consistent indicator of fetal distress.
Full Explanation
Choice A reason: AFI stands for amniotic fluid index, which is a measurement of the amount of amniotic fluid surrounding the fetus. AFI is an indicator of fetal well-being, as it reflects the fetal urine output and the placental function. A normal AFI is between 5 and 25 cm. A low AFI (< 5 cm) can suggest fetal growth restriction, oligohydramnios, or fetal distress. A high AFI (> 25 cm) can suggest fetal anomalies, polyhydramnios, or maternal diabetes.
Choice B reason: Fetal heart rate is an assessment of the fetal cardiac activity, which is usually monitored by a non-stress test (NST). Fetal heart rate is an indicator of fetal well-being, as it reflects the fetal oxygenation and the autonomic nervous system. A normal fetal heart rate is between 110 and 160 beats per minute, with moderate variability and accelerations. A non-reactive fetal heart rate (< 2 accelerations in 20 minutes) can suggest fetal hypoxia, acidosis, or distress.
Choice C reason: Fetal movement is an assessment of the fetal gross body movements, which are usually counted by the mother or observed by ultrasound. Fetal movement is an indicator of fetal well-being, as it reflects the fetal activity and the central nervous system. A normal fetal movement is at least 3 movements in 30 minutes. A decreased fetal movement (< 3 movements in 2 hours) can suggest fetal sleep, sedation, or distress.
Choice D reason: Fetal tone is an assessment of the fetal muscle tone, which is usually observed by ultrasound. Fetal tone is an indicator of fetal well-being, as it reflects the fetal maturity and the neuromuscular system. A normal fetal tone is at least 1 episode of fetal flexion or extension in 30 minutes. An abnormal fetal tone (absent or hypotonic) can suggest fetal immaturity, anomalies, or distress.
Choice E reason: Placental grade is not an assessment that is included in the fetal biophysical profile (BPP), as it is not a direct measure of fetal well-being, but rather a classification of the placental maturity and calcification. Placental grade is usually evaluated by ultrasound, and it ranges from 0 to 3, with higher grades indicating more calcification and aging. Placental grade can affect the placental function and the fetal growth, but it is not a reliable or consistent indicator of fetal distress.
A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has been diagnosed with hyperemesis gravidarum. Which of the following is not a risk factor for hyperemesis gravidarum?
A. Molar pregnancy
Molar pregnancy is a risk factor for hyperemesis gravidarum, as it is a gestational trophoblastic disease that causes an abnormal growth of the placenta and the production of high levels of human chorionic gonadotropin (hCG), which is a hormone that stimulates nausea and vomiting. Molar pregnancy can cause severe and persistent hyperemesis gravidarum, as well as vaginal bleeding, uterine enlargement, and preeclampsia.
B. Previous history of hyperemesis gravidarum
Previous history of hyperemesis gravidarum is a risk factor for hyperemesis gravidarum, as it suggests a genetic or physiological predisposition to the condition. Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs in pregnancy, and it can cause dehydration, electrolyte imbalance, weight loss, and malnutrition. Hyperemesis gravidarum can recur in subsequent pregnancies, especially if the mother has the same partner, the same sex of the fetus, or a short interval between pregnancies.
C. Oligohydramnios
Oligohydramnios is not a risk factor for hyperemesis gravidarum, as it is a low level of amniotic fluid that surrounds the fetus. Oligohydramnios is not related to hyperemesis gravidarum, and it is not a cause or a consequence of it. Oligohydramnios can affect the fetal development and the delivery, as it can cause fetal growth restriction, cord compression, or meconium aspiration.
D. Multiple fetal gestation
Multiple fetal gestation is a risk factor for hyperemesis gravidarum, as it is a condition where the mother is carrying more than one fetus. Multiple fetal gestation can cause higher levels of hCG, estrogen, and progesterone, which are hormones that stimulate nausea and vomiting. Multiple fetal gestation can cause more severe and prolonged hyperemesis gravidarum, as well as preterm labor, anemia, and preeclampsia.
Full Explanation
Choice A reason: Molar pregnancy is a risk factor for hyperemesis gravidarum, as it is a gestational trophoblastic disease that causes an abnormal growth of the placenta and the production of high levels of human chorionic gonadotropin (hCG), which is a hormone that stimulates nausea and vomiting. Molar pregnancy can cause severe and persistent hyperemesis gravidarum, as well as vaginal bleeding, uterine enlargement, and preeclampsia.
Choice B reason: Previous history of hyperemesis gravidarum is a risk factor for hyperemesis gravidarum, as it suggests a genetic or physiological predisposition to the condition. Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs in pregnancy, and it can cause dehydration, electrolyte imbalance, weight loss, and malnutrition. Hyperemesis gravidarum can recur in subsequent pregnancies, especially if the mother has the same partner, the same sex of the fetus, or a short interval between pregnancies.
Choice C reason: Oligohydramnios is not a risk factor for hyperemesis gravidarum, as it is a low level of amniotic fluid that surrounds the fetus. Oligohydramnios is not related to hyperemesis gravidarum, and it is not a cause or a consequence of it. Oligohydramnios can affect the fetal development and the delivery, as it can cause fetal growth restriction, cord compression, or meconium aspiration.
Choice D reason: Multiple fetal gestation is a risk factor for hyperemesis gravidarum, as it is a condition where the mother is carrying more than one fetus. Multiple fetal gestation can cause higher levels of hCG, estrogen, and progesterone, which are hormones that stimulate nausea and vomiting. Multiple fetal gestation can cause more severe and prolonged hyperemesis gravidarum, as well as preterm labor, anemia, and preeclampsia.