Question

A nurse suspects that a pregnant client may be experiencing a placental abruption (abruptio placentae) based on an assessment of which finding(s)? Select all that apply.

Answer 1

Correct Answers:

dark red vaginal bleeding
rigid uterus
absent fetal heart tones

Rationale :

🩸Dark red vaginal bleeding is a characteristic manifestation of placental abruption, although bleeding can be concealed behind the placenta.

👉A rigid, boardlike uterus develops because blood irritates the uterine muscle, causing persistent uterine contraction and tenderness.

💔Absent fetal heart tones can occur with a severe abruption because placental separation interrupts fetal oxygen delivery and can cause fetal death.

⚡Placental abruption usually has a sudden onset and is commonly associated with abdominal or uterine pain rather than painless bleeding.

📌Core Message

Placental abruption commonly presents with dark vaginal bleeding, a rigid painful uterus, and possible fetal compromise.

Answer 2

Correct Answers:

"Pain is frequently mistaken for irritability or agitation."

Rationale :

😣Newborns experience pain during invasive procedures despite being unable to describe their discomfort verbally.

👶Signs of neonatal pain can include crying, facial grimacing, body movements, altered vital signs, irritability, or agitation.

🧩Because these behaviors are nonspecific, pain responses may be incorrectly interpreted as ordinary irritability or restlessness.

🩺Nurses must use validated newborn pain-assessment tools and provide appropriate nonpharmacological or pharmacological pain relief.

📌Core Message

Newborn pain is real but may be overlooked because its behavioral signs can resemble irritability or agitation.

Answer 3

Correct Answers:

Yellowing of the eyes and skin
Respiratory rate 71 breaths/min
Blood glucose level low

Rationale :

🥶Cold stress increases the newborn’s metabolic rate, oxygen consumption, and use of glucose to generate heat.

🌬️A respiratory rate of 71 breaths/min indicates tachypnea and can occur because cold stress increases oxygen demand and respiratory effort.

🍬A low blood glucose level develops when glucose is rapidly consumed during nonshivering thermogenesis.

🟡Prolonged cold stress can contribute to jaundice because hypoxia and metabolic disturbances interfere with normal bilirubin processing.

📌Core Message

Newborn cold stress can cause tachypnea, hypoglycemia, metabolic acidosis, and jaundice when warming is not restored promptly.

Answer 4

Correct Answers:

Macrosomia
Expelled blood clots
Surgical birth
Prolonged labor
Labor induction

Rationale :

🐘Macrosomia causes uterine overdistention, which can prevent the uterus from contracting effectively after delivery.

🩸Expelled blood clots can indicate blood pooling in a poorly contracted uterus and require immediate fundal assessment.

🏥A surgical birth increases the risk of postpartum hemorrhage and requires close monitoring of uterine tone and bleeding.

⏳Prolonged labor and labor induction can exhaust or overstimulate uterine muscle, increasing the likelihood of uterine atony.

📌Core Message

Uterine atony should be prioritized when uterine overdistention, prolonged or induced labor, surgical birth, or abnormal clot passage is documented.

Answer 5

Correct Answers:

Antiemetic to minimize nausea

Rationale :

🤢An antiemetic may be administered before mifepristone to reduce expected nausea or vomiting associated with the medication regimen.

💊Preventing vomiting helps improve medication tolerance and reduces the possibility that an oral dose will not be retained.

🩹An opioid is not routinely administered before mifepristone because significant uterine cramping usually occurs after the prostaglandin medication is given.

📋The nurse should also monitor for heavy bleeding, severe pain, infection, or incomplete passage of the retained products.

📌Core Message

An antiemetic may be administered before mifepristone to reduce nausea and improve tolerance of the medication regimen.

Answer 6

Correct Answers:

Did not receive vitamin K injection at birth

Rationale :

💉A newborn who did not receive the vitamin K injection has an increased risk of excessive bleeding during or after circumcision.

🩸Newborns naturally have limited vitamin K stores, which are needed to produce several clotting factors.

✂️Circumcision should be postponed until the healthcare provider evaluates the newborn and appropriate bleeding prophylaxis is provided.

🛡️Administration of vitamin K shortly after birth substantially reduces the risk of vitamin K deficiency bleeding.

📌Core Message

A newborn should receive vitamin K before circumcision to reduce the risk of uncontrolled bleeding.

Answer 7

Correct Answers:

Pulmonary vascular resistance is decreased as the lungs begin to function.

Rationale :

👉With the newborn’s first breaths, lung expansion increases oxygen levels and causes pulmonary blood vessels to dilate.

📉This vasodilation produces a rapid decrease in pulmonary vascular resistance, allowing more blood to flow through the lungs.

❤️Increased pulmonary blood flow raises left-sided heart pressure and contributes to functional closure of the foramen ovale.

🔄These cardiopulmonary changes are essential for replacing placental gas exchange with effective extrauterine breathing.

📌Core Message

After birth, pulmonary vascular resistance decreases as the lungs expand, increasing pulmonary blood flow and supporting extrauterine oxygenation.

Answer 8

Correct Answers:

Methylergonovine

Rationale :

💉Methylergonovine is a uterotonic medication that produces strong uterine contractions and can reduce severe postpartum bleeding caused by uterine atony.

🩸Following delivery, effective uterine contraction compresses the open blood vessels at the placental attachment site.

🧯Methylergonovine may be administered when bleeding persists despite initial interventions such as fundal massage or oxytocin.

⚠️The nurse must assess for hypertension because methylergonovine can cause significant vasoconstriction and elevated blood pressure.

📌Core Message

Methylergonovine controls atonic postpartum bleeding by producing sustained uterine contraction but should be avoided in clients with hypertension.

Answer 9

Correct Answers:

Shortened

Rationale :

📏A shortened cervix indicates cervical effacement, which is an important component of cervical ripening.

🌸A ripe cervix becomes soft, moves toward an anterior position, shortens, and begins to dilate.

👉The Bishop score assesses dilation, effacement, consistency, position, and fetal station to estimate readiness for induction.

🚦Greater cervical effacement increases the likelihood that labor induction will result in successful vaginal birth.

📌Core Message

A ripe cervix is soft, anterior, shortened or effaced, and beginning to dilate in preparation for labor induction.

Answer 10

Correct Answers:

"Your baby does not have enough surfactant to assist with the ease of breathing."

Rationale :

👤A newborn delivered at 26 weeks’ gestation has immature lungs with an insufficient amount of surfactant.

🎈Surfactant reduces surface tension within the alveoli and helps prevent alveolar collapse during exhalation.

📉A surfactant deficiency causes decreased lung compliance, atelectasis, increased breathing effort, and respiratory distress syndrome.

👉The premature newborn may require respiratory support and administration of exogenous surfactant to improve oxygenation.

📌Core Message

A newborn born at 26 weeks commonly develops respiratory distress because insufficient surfactant allows alveolar collapse and increases breathing effort.

1 :
A nurse suspects that a pregnant client may be experiencing a placental abruption (abruptio placentae) based on an assessment of which finding(s)? Select all that apply.

📌Core Message

2 :
A nurse is teaching a group of nursing students about newborn pain management. Which statement by a student indicates they have understood the teaching?

📌Core Message

Newborn pain is real but may be overlooked because its behavioral signs can resemble irritability or agitation.

3 :
A newborn is experiencing cold stress. Which finding(s) does the nurse expect to assess? Select all that apply.

📌Core Message

4 :
A nurse is taking over care for a client who gave birth to a healthy newborn 1 hour ago. Which finding(s) in the chart informs the nurse's decision to prioritize the assessment for uterine atony? Select all that apply.

📌Core Message

5 :
A client who has experienced an incomplete abortion is prescribed mifepristone to assist in removing the retained products of conception. Which medication does the nurse expect to administer before administering mifepristone?

📌Core Message

6 :
The nurse is caring for a newborn who is scheduled to get a circumcision in 30 minutes. Which finding should the nurse report to the health care provider?

📌Core Message

7 :
A nurse is explaining to a group of new parents the changes that occur in the newborn to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information will the nurse integrate into the explanation to support this description?

📌Core Message

8 :
The nurse is caring for a client experiencing severe vaginal bleeding after a traumatic delivery. Which medication does the nurse expect to administer in this situation?

📌Core Message

9 :
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding indicates to the nurse that the client's cervix is ripe in preparation for the induction?

📌Core Message

10 :
The nurse is caring for a newborn who was born at 26 weeks' gestation. The parents ask why the newborn is having trouble breathing. Which response by the nurse is best?

📌Core Message

1 : A nurse suspects that a pregnant client may be experiencing a placental abruption (abruptio placentae) based on an assessment of which finding(s)? Select all that apply.

📌Core Message

2 : A nurse is teaching a group of nursing students about newborn pain management. Which statement by a student indicates they have understood the teaching?

📌Core Message

Newborn pain is real but may be overlooked because its behavioral signs can resemble irritability or agitation.

3 : A newborn is experiencing cold stress. Which finding(s) does the nurse expect to assess? Select all that apply.

📌Core Message

4 : A nurse is taking over care for a client who gave birth to a healthy newborn 1 hour ago. Which finding(s) in the chart informs the nurse's decision to prioritize the assessment for uterine atony? Select all that apply.

📌Core Message

5 : A client who has experienced an incomplete abortion is prescribed mifepristone to assist in removing the retained products of conception. Which medication does the nurse expect to administer before administering mifepristone?

📌Core Message

6 : The nurse is caring for a newborn who is scheduled to get a circumcision in 30 minutes. Which finding should the nurse report to the health care provider?

📌Core Message

7 : A nurse is explaining to a group of new parents the changes that occur in the newborn to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information will the nurse integrate into the explanation to support this description?

📌Core Message

8 : The nurse is caring for a client experiencing severe vaginal bleeding after a traumatic delivery. Which medication does the nurse expect to administer in this situation?

📌Core Message

9 : The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding indicates to the nurse that the client's cervix is ripe in preparation for the induction?

📌Core Message

10 : The nurse is caring for a newborn who was born at 26 weeks' gestation. The parents ask why the newborn is having trouble breathing. Which response by the nurse is best?

📌Core Message

1 :
A nurse suspects that a pregnant client may be experiencing a placental abruption (abruptio placentae) based on an assessment of which finding(s)? Select all that apply.

2 :
A nurse is teaching a group of nursing students about newborn pain management. Which statement by a student indicates they have understood the teaching?

3 :
A newborn is experiencing cold stress. Which finding(s) does the nurse expect to assess? Select all that apply.

4 :
A nurse is taking over care for a client who gave birth to a healthy newborn 1 hour ago. Which finding(s) in the chart informs the nurse's decision to prioritize the assessment for uterine atony? Select all that apply.

5 :
A client who has experienced an incomplete abortion is prescribed mifepristone to assist in removing the retained products of conception. Which medication does the nurse expect to administer before administering mifepristone?

6 :
The nurse is caring for a newborn who is scheduled to get a circumcision in 30 minutes. Which finding should the nurse report to the health care provider?

7 :
A nurse is explaining to a group of new parents the changes that occur in the newborn to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information will the nurse integrate into the explanation to support this description?

8 :
The nurse is caring for a client experiencing severe vaginal bleeding after a traumatic delivery. Which medication does the nurse expect to administer in this situation?

9 :
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding indicates to the nurse that the client's cervix is ripe in preparation for the induction?

10 :
The nurse is caring for a newborn who was born at 26 weeks' gestation. The parents ask why the newborn is having trouble breathing. Which response by the nurse is best?