Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for:
A. infection.
Infection is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Marginal placenta previa is a type of placenta previa where the edge of the placenta is near the cervical os but does not cover it. It can cause painless bleeding during pregnancy or labor, but it does not increase the risk of infection.
B. hemorrhage.
Hemorrhage is the greatest risk for a woman with marginal placenta previa, as it can occur due to the separation of the placenta from the uterine wall during labor or delivery. The bleeding can be profuse and life-threatening, and it requires prompt intervention and monitoring.
C. urinary retention.
Urinary retention is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Urinary retention is the inability to empty the bladder completely, and it can occur due to various factors such as anesthesia, trauma, or medication. It can cause discomfort, infection, or bladder distension, but it is not as serious as hemorrhage.
D. thrombophlebitis.
Thrombophlebitis is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Thrombophlebitis is the inflammation of a vein due to a blood clot, and it can occur due to prolonged bed rest, dehydration, or injury. It can cause pain, swelling, or redness in the affected area, and it can lead to pulmonary embolism if the clot dislodges and travels to the lungs. However, it is not as common or as severe as hemorrhage.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Midterm Proctored Exam 1. Take the full exam now
Full Explanation
Choice A reason: Infection is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Marginal placenta previa is a type of placenta previa where the edge of the placenta is near the cervical os but does not cover it. It can cause painless bleeding during pregnancy or labor, but it does not increase the risk of infection.
Choice B reason: Hemorrhage is the greatest risk for a woman with marginal placenta previa, as it can occur due to the separation of the placenta from the uterine wall during labor or delivery. The bleeding can be profuse and life-threatening, and it requires prompt intervention and monitoring.
Choice C reason: Urinary retention is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Urinary retention is the inability to empty the bladder completely, and it can occur due to various factors such as anesthesia, trauma, or medication. It can cause discomfort, infection, or bladder distension, but it is not as serious as hemorrhage.
Choice D reason: Thrombophlebitis is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Thrombophlebitis is the inflammation of a vein due to a blood clot, and it can occur due to prolonged bed rest, dehydration, or injury. It can cause pain, swelling, or redness in the affected area, and it can lead to pulmonary embolism if the clot dislodges and travels to the lungs. However, it is not as common or as severe as hemorrhage.
Similar Questions
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:
A. intense abdominal pain.
Intense abdominal pain is the most prevalent clinical manifestation of abruptio placentae, as it indicates the detachment of the placenta from the uterine wall and the bleeding into the uterine muscle. The pain can be localized or diffuse, and it can be constant or intermittent. The pain can also radiate to the back or the shoulder.
B. cramping.
Cramping is not the most prevalent clinical manifestation of abruptio placentae, as it is not specific to the condition. Cramping can occur in normal pregnancy or in other complications such as preterm labor, infection, or cervical insufficiency.
C. uterine activity.
Uterine activity is not the most prevalent clinical manifestation of abruptio placentae, as it is not specific to the condition. Uterine activity can occur in normal pregnancy or in other complications such as preterm labor, infection, or placenta previa.
D. bleeding.
Bleeding is not the most prevalent clinical manifestation of abruptio placentae, as it may or may not be present. Bleeding can be concealed or revealed, depending on the location and extent of the placental separation. Concealed bleeding occurs when the blood is trapped behind the placenta and does not exit the vagina. Revealed bleeding occurs when the blood passes through the cervix and exits the vagina.
Full Explanation
Choice A reason: Intense abdominal pain is the most prevalent clinical manifestation of abruptio placentae, as it indicates the detachment of the placenta from the uterine wall and the bleeding into the uterine muscle. The pain can be localized or diffuse, and it can be constant or intermittent. The pain can also radiate to the back or the shoulder.
Choice B reason: Cramping is not the most prevalent clinical manifestation of abruptio placentae, as it is not specific to the condition. Cramping can occur in normal pregnancy or in other complications such as preterm labor, infection, or cervical insufficiency.
Choice C reason: Uterine activity is not the most prevalent clinical manifestation of abruptio placentae, as it is not specific to the condition. Uterine activity can occur in normal pregnancy or in other complications such as preterm labor, infection, or placenta previa.
Choice D reason: Bleeding is not the most prevalent clinical manifestation of abruptio placentae, as it may or may not be present. Bleeding can be concealed or revealed, depending on the location and extent of the placental separation. Concealed bleeding occurs when the blood is trapped behind the placenta and does not exit the vagina. Revealed bleeding occurs when the blood passes through the cervix and exits the vagina.
The nurse should include which information when teaching a 15-year old about genital tract infection prevention? Select all that apply
A. Limit time spent wearing a wet bathing suit
Limiting time spent wearing a wet bathing suit is a good preventive measure, as it can reduce the moisture and warmth that can promote the growth of bacteria and fungi in the genital area. The nurse should advise the 15-year old to change into dry clothes as soon as possible after swimming or bathing.
B. Do not douche.
Not douching is a good preventive measure, as it can preserve the natural balance of the vaginal flora and pH. The nurse should explain to the 15-year old that douching can wash away the protective mucus and lactobacilli that prevent infections, and it can also introduce harmful substances or microorganisms into the vagina.
C. Wear nylon undergarments
Wearing nylon undergarments is not a good preventive measure, as it can trap heat and moisture in the genital area and create a favorable environment for infections. The nurse should recommend the 15-year old to wear cotton or breathable fabrics that can absorb sweat and allow air circulation.
D. Use floral scented bath salts
Using floral scented bath salts is not a good preventive measure, as it can irritate the genital mucosa and alter the vaginal pH. The nurse should caution the 15-year old to avoid using any products that contain perfumes, dyes, or chemicals in the genital area, as they can cause allergic reactions or infections.
E. Decrease sugar intake.
Decreasing sugar intake is a good preventive measure, as it can lower the risk of yeast infections. The nurse should educate the 15-year old that sugar can feed the growth of Candida albicans, which is a common cause of vaginal candidiasis. The nurse should also encourage the 15-year old to eat a balanced diet that includes probiotics, such as yogurt, to maintain a healthy vaginal flora.
F. Avoid tight-fitting jeans.
Avoiding tight-fitting jeans is a good preventive measure, as it can prevent friction and pressure on the genital area. The nurse should suggest the 15-year old to wear loose or comfortable clothing that can reduce the risk of skin irritation or injury, which can lead to infections.
Full Explanation
Choice A reason: Limiting time spent wearing a wet bathing suit is a good preventive measure, as it can reduce the moisture and warmth that can promote the growth of bacteria and fungi in the genital area. The nurse should advise the 15-year old to change into dry clothes as soon as possible after swimming or bathing.
Choice B reason: Not douching is a good preventive measure, as it can preserve the natural balance of the vaginal flora and pH. The nurse should explain to the 15-year old that douching can wash away the protective mucus and lactobacilli that prevent infections, and it can also introduce harmful substances or microorganisms into the vagina.
Choice C reason: Wearing nylon undergarments is not a good preventive measure, as it can trap heat and moisture in the genital area and create a favorable environment for infections. The nurse should recommend the 15-year old to wear cotton or breathable fabrics that can absorb sweat and allow air circulation.
Choice D reason: Using floral scented bath salts is not a good preventive measure, as it can irritate the genital mucosa and alter the vaginal pH. The nurse should caution the 15-year old to avoid using any products that contain perfumes, dyes, or chemicals in the genital area, as they can cause allergic reactions or infections.
Choice E reason: Decreasing sugar intake is a good preventive measure, as it can lower the risk of yeast infections. The nurse should educate the 15-year old that sugar can feed the growth of Candida albicans, which is a common cause of vaginal candidiasis. The nurse should also encourage the 15-year old to eat a balanced diet that includes probiotics, such as yogurt, to maintain a healthy vaginal flora.
Choice F reason: Avoiding tight-fitting jeans is a good preventive measure, as it can prevent friction and pressure on the genital area. The nurse should suggest the 15-year old to wear loose or comfortable clothing that can reduce the risk of skin irritation or injury, which can lead to infections.
A nurse counseling a client with endometriosis understands which statements regarding the management of endometriosis are accurate? (Select all that apply)
A. Women without pain and who do not want to become pregnant need no treatment.
None
B. Surgical intervention often is needed for severe or acute symptoms.
None
C. Side effects from the steroid danazol include masculinizing traits.
None
D. Bone loss from hypoestrogenism is not reversible.
None
E. Take NSAIDs to manage pain.
Women with mild pain who may want a future pregnancy may take nonsteroidal anti-inflammatory drugs (NSAIDs), as NSAIDs can reduce the inflammation and pain caused by endometriosis. The nurse should recommend the client to take NSAIDs as needed, and to follow the dosage and instructions on the label. The nurse should also inform the client that NSAIDs are not effective in treating the underlying cause of endometriosis, and that they may have side effects such as gastrointestinal irritation, bleeding, or ulcers.
Full Explanation
Choice A reason: Women without pain and who do not want to become pregnant need no treatment, as endometriosis is a benign condition that does not affect the general health or well-being of the woman. The nurse should explain to the client that endometriosis is a chronic condition that causes the growth of endometrial tissue outside the uterus, and that it can cause symptoms such as pelvic pain, dysmenorrhea, dyspareunia, and infertility. However, if the woman is asymptomatic and has no desire for pregnancy, she can choose to monitor the condition without any intervention.
Choice B reason: Surgical intervention often is needed for severe or acute symptoms, as endometriosis can cause complications such as adhesions, cysts, inflammation, or obstruction of the pelvic organs. The nurse should inform the client that surgery can be performed to remove or destroy the endometrial implants, or to perform a hysterectomy or oophorectomy in severe cases. The nurse should also discuss the benefits and risks of surgery, and the possibility of recurrence or persistence of symptoms.
Choice C reason: Side effects from the steroid danazol include masculinizing traits, as danazol is a synthetic androgen that suppresses the ovarian function and reduces the production of estrogen and progesterone. The nurse should warn the client that danazol can cause adverse effects such as acne, hirsutism, weight gain, voice changes, decreased breast size, and menstrual irregularities. The nurse should also advise the client to use a non-hormonal contraceptive method while taking danazol, as it can harm the fetus if pregnancy occurs.
Choice D reason: Bone loss from hypoestrogenism is not irreversible, as it can be prevented or treated with calcium and vitamin D supplements, bisphosphonates, or hormone replacement therapy. The nurse should educate the client that hypoestrogenism is a condition where the estrogen levels are abnormally low, and that it can occur as a result of some medications or surgical procedures for endometriosis. The nurse should also explain that hypoestrogenism can increase the risk of osteoporosis, which is a condition where the bones become weak and brittle.
Choice E reason: Women with mild pain who may want a future pregnancy may take nonsteroidal anti-inflammatory drugs (NSAIDs), as NSAIDs can reduce the inflammation and pain caused by endometriosis. The nurse should recommend the client to take NSAIDs as needed, and to follow the dosage and instructions on the label. The nurse should also inform the client that NSAIDs are not effective in treating the underlying cause of endometriosis, and that they may have side effects such as gastrointestinal irritation, bleeding, or ulcers.