Question 1

Which situation in the high-risk antepartal unit requires immediate intervention?

Accepted Answer

A patient who is pregnant with twins and who underwent an appendectomy yesterday should not be placed in a supine position as it can compress the inferior vena cava leading to decreased blood flow and oxygenation to the fetuses. This situation requires immediate intervention to change the patient's position to a left lateral position to alleviate the compression on the inferior vena cava. The other options may require interventions but they are not emergent situations.

Question 2

Which maternal-child patient should the nurse see first?

Accepted Answer

A positive Direct Coombs' test indicates the presence of antibodies on the baby's red blood cells, which can lead to hemolytic disease of the newborn. This requires immediate attention from the healthcare team.

Question 3

The nurse identifies the following assessment findings on a patient with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet. On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the pre-eclampsia?

Accepted Answer

A decrease in urinary output indicates worsening kidney function, which is a common complication of pre-eclampsia. The increase in blood pressure is already a known finding and may not significantly change management in the short term. Reflexes of 21 are within the normal range and a platelet count of 150,000 is also within normal limits.

Question 4

A patient who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing?

Accepted Answer

ABO incompatibility occurs when a mother's blood type is different from her baby's blood type. This can cause the baby's red blood cells to break down and lead to hyperbilirubinemia, which can cause brain damage if not treated. Therefore, the nurse should anticipate carefully assessing the neonate for the development of hyperbilirubinemia. Intramuscular administration of Rh immune globulin (RhoGAM) is used for Rh incompatibility, not ABO incompatibility. While notifying the patient's primary care provider and obtaining an antibody screen may be necessary in some cases, they do not directly address the risk of hyperbilirubinemia in the neonate.

Question 5

The prenatal clinic nurse is caring for a patient with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?

Accepted Answer

The patient's vital signs indicate she is in a state of dehydration, and the first priority should be to administer IV fluids to replace lost fluids and electrolytes. Weighing the patient is important in monitoring fluid status, but it should not be the first priority. Administering an antacid such as Maalox and encouraging clear liquids are important interventions, but they do not address the patient's immediate need for hydration.

Question 6

The nurse is admitting a patient 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?

Accepted Answer

The most critical question to ask is whether the patient has a safe place to go as it concerns their immediate safety. Asking about past incidents or pressing charges can wait until the patient's safety is ensured. Asking about what the patient did to make their spouse angry can also be potentially harmful, blaming the victim for the abuse.

Question 7

Which statement indicates that teaching has been effective?

Accepted Answer

Group B streptococcus (GBS) is a type of bacterial infection that can be found in a pregnant woman's vagina or rectum and can lead to serious infections in newborns, such as sepsis, pneumonia, and meningitis. The statement reflects an understanding of the potential risks associated with GBS during pregnancy and the importance of appropriate management to prevent neonatal infection.

Question 8

The patient with blood type A, Rh-negative delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?

Accepted Answer

RhoGAM is given to Rh-negative mothers who deliver Rh-positive infants to prevent Rh sensitization, which can cause complications in future pregnancies.

Question 9

The nurse is supervising care in the emergency department. Which situation most requires an intervention?

Accepted Answer

The bright red bleeding with clots at 32 weeks' gestation along with the patient's elevated heart rate, low blood pressure, and respiratory rate require immediate intervention as these are signs of severe hemorrhage and may indicate an imminent risk to the mother and fetus. The other options also require nursing intervention, but they are not as urgent as option C.

Question 10

The community nurse is working with a patient at 32 weeks' gestation who has been diagnosed with pre-eclampsia. Which statement indicates that additional information is needed?

Accepted Answer

Darker and smaller amounts of urine may indicate dehydration, but pre-eclampsia is typically associated with increased urine output and sometimes even excess protein in urine. Therefore, this statement indicates a potential misunderstanding about the patient's condition and should be further assessed by the community nurse.

Question 11

The nurse is assessing a newly admitted patient who is 32 weeks' gestation. The patient's chief complaints are sudden onset of intense nausea and a frontal headache for the past two days. The patient's initial blood pressure is 158/98 and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing?

Accepted Answer

Sudden onset of intense nausea, frontal headache, and high blood pressure in a patient who is 32 weeks' gestation may be indicative of preeclampsia. The nurse should conduct a urine dipstick test to assess for proteinuria, which is a hallmark feature of preeclampsia. Placing a wedge under the patient's left hip so that she is in a right lateral tilt position is more appropriate for a patient in the third trimester who is experiencing supine hypotensive syndrome. Administration of diuretics and facilitating a dietary regimen of strict sodium restriction may be indicated for edema management, but not for the presented clinical picture. Ordering a low-protein diet plan for the patient is not the primary intervention for suspected preeclampsia.

Question 12

While preparing a class on maternal-fetal ABO incompatibility for antepartum patients, the nurse is creating a brochure. Which statement should be included in the brochure information?

Accepted Answer

ABO incompatibility typically occurs in pregnancies where the mother is blood type O and the baby is either blood type A or B. This is because type O blood contains anti-A and anti-B antibodies, which can cross the placenta and attack the fetus's red blood cells if they are of a different ABO blood type.

Question 13

The nurse receives the following report on a patient 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?

Accepted Answer

The priority action for the nurse should be to determine if RhoGAM has been given. The mother is A-negative and the baby is B-positive, which indicates a potential for Rh incompatibility. If the mother is Rh negative and the baby is Rh positive, there is a risk for the mother to develop antibodies against the baby’s blood in future pregnancies. RhoGAM is a medication that prevents this from happening, and it should be given within 72 hours of delivery.

Question 14

A 28-year-old woman who is at 16 weeks' gestation has just undergone screening for ABO incompatibility. She asks the nurse why her blood contains anti-A antibodies. What is the nurse's best response?

Accepted Answer

Anti-A antibodies occur naturally in individuals who do not have the A antigen on their red blood cells. Exposure to different foods and infections can stimulate the body to produce these antibodies.

Question 15

The nurse is caring for a patient at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern?

Accepted Answer

The answer of The nurse is caring for a patient...

Quiz 16: Pregnancy at Risk: Gestational Onset