Chapter 15 Flashcards
The nurse is supervising care in the emergency department. Which situation requires immediate intervention?
Bright red bleeding with clots at 32 weeks’ gestation; pulse = 110, blood pressure 90/50, respirations = 20.
A pregnant client at 14 weeks’ gestation is diagnosed with hyperemesis gravidarum. The most recent vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?
Give 1 L of lactated Ringer solution IV.
A 28-year-old woman at 16 weeks’ gestation being screened for ABO incompatibility learns that her blood contains anti-A antibodies. What should the nurse explain about this finding?
“Anti-A antibodies occur naturally, as a result of exposure to foods and different infections.”
The nurse is preparing teaching on maternal–fetal ABO incompatibility for antepartum clients. Which statement should the nurse include in the teaching information?
In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus.
A client who is at 32 weeks’ gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing?
Note the potential for ABO incompatibility and plan to carefully assess the neonate for the development of hyperbilirubinemia.
A client with preeclampsia is assessed with the following: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. Which new assessment finding indicates the client’s condition is getting worse?
Urinary output 20 mL/hour
The community nurse is caring for a client at 32 weeks’ gestation diagnosed with preeclampsia. Which statement indicates that additional information is needed about the health problem?
“My urine may become darker and smaller in amount each day.”
A newly admitted client at 32 weeks’ gestation is experiencing a sudden onset of intense nausea and a frontal headache for the past 2 days. The client’s initial blood pressure is 158/98, and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing?
Conducting a urine dipstick test to assess for proteinuria
The nurse receives the following report on a client who delivered 36 hours ago: para 1, rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse?
Determine if RhoGAM has been given.
A postpartum client with blood type A, Rh-negative delivered a newborn with blood type AB, Rh-positive. Which statement indicates that teaching about this blood type inconsistency has been effective?
“I need to get RhoGAM so I do not have problems with my next pregnancy.”
Which maternal–child client should the nurse see first?
Direct Coombs test positive
Which situation in the high-risk antepartal unit requires immediate intervention?
A third-trimester client pregnant with twins who required an appendectomy yesterday is positioned in a supine position.
The nurse is caring for a client at 35 weeks’ gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern?
“Entrance wound present below the umbilicus.”
The nurse is admitting a client at 28 weeks’ gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask?
“Do you have a safe place where you can go?”
The nurse instructs a client on the importance of reducing exposure to infections while pregnant. Which client statement indicates that teaching has been effective?
“My baby may develop a serious blood infection because I have group B strep in my vagina.”
