NR-327 Maternal-Child Nursing - Set 2 - Part 2

Correct Answer: Hyperemesis gravidarum with dehydration and starvation ketosis

Weight loss, ketonuria and dehydration are what separate hyperemesis gravidarum from ordinary nausea and vomiting. The persistent vomiting drives fluid and electrolyte loss, and fat breakdown from starvation produces the ketones in her urine. Option b is incorrect because typical first trimester nausea does not cost the client weight or spill ketones into the urine. Women with ordinary symptoms keep enough down to stay hydrated and continue gaining. Option c is incorrect because an infectious cause would bring diarrhea, fever or a sick contact, and it would resolve within days. Two weeks of daily vomiting beginning in early pregnancy points elsewhere. Option d is incorrect because reflux produces burning behind the sternum and a sour taste rather than repeated emesis severe enough to strip body weight. Relief measures for heartburn would not touch this client's problem.

Correct Answer: Take the client's blood pressure and pulse

Measuring routine vital signs on a stable client sits within the assistive role. Reading the fetal tracing, giving an injection and teaching danger signs all require nursing judgment and stay with the nurse. Option a is incorrect because judging whether the heart rate accelerates calls for assessment skill that assistive personnel do not hold. Recognizing a worrying pattern after the needle is exactly what the recovery watch exists for. Option b is incorrect because client education is a nursing responsibility that cannot be handed off. The list of complications to report shapes what the client does at home, and it requires someone able to answer questions. Option c is incorrect because medication administration falls outside the assistive scope in every state. Immune globulin also demands verification of blood type and antibody status first, a check only a licensed nurse may complete.

Correct Answer: Keep the room dim and cluster nursing care

Bright light, noise and repeated interruptions raise cerebral irritability in an already hyperreflexic client. A dim, quiet room with grouped care lowers stimulation, and padded rails with tested suction and oxygen complete the precautions. Option b is incorrect because a stream of visitors is exactly the stimulation the plan is designed to remove. Anxiety is eased instead by a calm explanation, a quiet room and a nurse who stays predictable. Option c is incorrect because walking a client who could convulse without warning invites a fall in the corridor. Activity is limited, and she is kept where suction, oxygen and padded rails are within reach. Option d is incorrect because a raised bed turns a convulsion into a fall from height. Seizure precautions call for the lowest position with the rails up and padded, which staff can still lower quickly.

Correct Answer: Fetal insulin stays high after the glucose supply stops

The fetus made extra insulin to handle the mother's glucose, and that high insulin level persists after the cord is clamped. With the maternal supply gone, blood glucose falls quickly in the first hours. Option a is incorrect because maternal insulin is too large a molecule to reach the fetus. Only glucose crosses by facilitated diffusion, which is exactly why the fetal pancreas had to make its own supply. Option c is incorrect because glycogen stores describe the preterm or growth restricted infant, whose reserves never accumulated. This infant of a diabetic mother is typically large and well stocked, yet burns through those stores fast. Option d is incorrect because cold stress does drain glucose, but nothing in this scenario suggests a chilled newborn. The maternal diabetes in the history points directly at hyperinsulinemia as the cause.

Correct Answer: Screening is done for every client between 24 and 28 weeks

All pregnant clients are screened for gestational diabetes between 24 and 28 weeks regardless of risk, because insulin resistance driven by placental hormones peaks in the second half of pregnancy and glucose intolerance surfaces then. Option a is incorrect because risk based testing alone would miss the many clients who develop gestational diabetes without any identifiable risk factor. Those with risk factors are simply screened earlier, before 15 weeks, in addition to the universal test. Option b is incorrect because a fasting specimen early in pregnancy detects diabetes that predated conception rather than the gestational form. The glucose challenge given later needs no fasting and is deliberately timed to the resistant phase. Option d is incorrect because repeated testing at every visit serves no purpose and burdens the client without improving detection. One properly timed challenge identifies who needs the longer tolerance test that actually confirms the diagnosis.

Correct Answer: Preparing lubricant for a cervical dilation check

Any digital cervical check is barred once previa is confirmed. Setting up for one signals the student is about to disturb a placenta lying over the os, so the nurse stops the action at once. Option a is incorrect because weighing pads converts a vague description into a measured volume, and every gram equals a milliliter. Accurate quantification is standard practice with any obstetric bleed and needs no correction. Option b is incorrect because talking through the imaging findings helps the client understand why a cesarean birth is planned. Teaching supports informed consent and poses no physical threat to the placenta. Option c is incorrect because side lying relieves pressure on the vena cava and improves blood flow to the uterus. That is the position of choice for a bleeding client, not an error to correct.

Correct Answer: Reactive nonstress test and negative contraction stress test

The two tests name their good results differently. Reactive is the reassuring word for the nonstress test because accelerations are present, while negative is the reassuring word for the stress test because late decelerations are absent. Option b is incorrect because half of this pairing is backwards. Nonreactive describes a strip that failed to produce two qualifying accelerations, which is the finding that sends a client on for a profile or a stress test. Option c is incorrect because a positive stress test is the alarming one, not the safe one. Late decelerations after most contractions mean the placenta cannot support labor, and that result usually leads to birth. Option d is incorrect because both halves name the worrying result rather than the reassuring one. A student who memorized this pairing would report a healthy fetus as compromised and a compromised fetus as healthy.

Correct Answer: Proceeding toward birth given the gestational age

An equivocal score suggests possible asphyxia and cannot be left alone. Past thirty-seven weeks the safer course is delivery, since the fetus gains little from remaining inside and the profile has already fallen short twice. Option a is incorrect because a week is far too long a gap after a borderline result. Repeat testing within a day belongs to the preterm client, while this pregnancy is already at a gestation where birth is safe. Option c is incorrect because home counting cannot substitute for a study that has already flagged a problem. Sending her away shifts surveillance onto the client at the moment the hospital has more to offer. Option d is incorrect because stopping surveillance abandons the fetus that the score has just called into question. Waiting for spontaneous labor leaves an interval during which the two missing components could worsen unobserved.

Correct Answer: Drink several glasses of water and avoid voiding

Early in pregnancy the uterus sits low in the pelvis. A full bladder lifts it and gives the sound waves a clear window, which is why the client drinks and holds urine until the images are captured. Option a is incorrect because fasting belongs to studies of the gallbladder or bowel, not to obstetric imaging. Food has no effect on the picture, and an empty stomach might leave this client lightheaded on the table. Option b is incorrect because voiding first is the rule for a transvaginal study, where a full bladder pushes the anatomy out of view. This client is having the probe placed on her abdomen instead. Option d is incorrect because antacids do nothing for image quality and are not part of any ultrasound protocol. Sound waves pass through fluid and tissue, so preparation targets the bladder rather than the stomach.

Correct Answer: The uterine tone and presence of pain

Palpation answers it. A soft, relaxed, non tender uterus with painless bleeding means previa, while a firm, rigid, tender uterus with constant pain means the placenta has already begun separating. Option a is incorrect because both conditions cluster in the third trimester, so timing alone cannot sort them. Previa bleeds as the lower segment thins, and separation can happen at any point after twenty weeks. Option b is incorrect because visible loss is the least trustworthy number in obstetric bleeding. A central separation can hide liters behind the placenta while the pad stays nearly clean and the client slides toward shock. Option c is incorrect because a single hemoglobin lags behind acute blood loss and looks falsely reassuring early, since whole blood leaves the body. It measures consequence rather than identifying which placental problem caused it.

Correct Answer: "Giving birth is the only treatment that cures this."

The disease begins in the placenta, so removing it removes the source. Drugs and monitoring buy time for fetal maturity, and birth is planned at thirty-four weeks or sooner if either client deteriorates. Option a is incorrect because lowering pressure protects the brain from stroke without touching the diseased placenta. Labetalol and hydralazine keep readings out of the danger zone, yet the endothelial injury continues unchanged underneath. Option b is incorrect because prolonged bed rest is no longer recommended for this diagnosis. It fails to alter the disease and raises the risk of clots in the legs and lungs, adding harm without benefit. Option d is incorrect because seizure prophylaxis does nothing to reopen narrowed spiral arteries. Magnesium raises the convulsive threshold in the maternal brain, leaving placental perfusion exactly as poor as it was beforehand.

Correct Answer: Blood is collecting behind the separating placenta

In a concealed separation the placental margins stay attached, so blood is trapped rather than escaping. The uterus enlarges, pain climbs, and the pulse rises while the pad stays almost dry. Option b is incorrect because a settled clot would leave her comfortable with stable vital signs. Climbing pain, a rising pulse, and a growing fundus all say bleeding is continuing where it cannot be seen. Option c is incorrect because a low lying placenta bleeds brightly and painlessly, leaving the uterus soft. Trauma, constant pain, and an expanding fundal measurement describe separation instead of misplaced implantation. Option d is incorrect because torn fetal vessels bleed at the moment membranes rupture and drop the fetal heart rate immediately while the mother stays stable. Her rising pulse shows the blood loss is maternal.

Correct Answer: Sharp right shoulder pain with sudden lightheadedness

Blood pooling under the diaphragm refers pain to the shoulder, and lightheadedness signals falling perfusion. Together they mean the tube has ruptured and she is bleeding into her abdomen right now. Option a is incorrect because queasiness after a heavy meal is common in early pregnancy and reflects slowed gastric emptying. It carries none of the urgency of referred pain from free intraabdominal blood. Option b is incorrect because rising hormone levels thicken glandular tissue and make the breasts sore, an expected change at this gestation. Reporting it deserves reassurance, not an emergency workup. Option c is incorrect because cramping that settles with rest suggests the pain is not escalating. Worsening, sudden, severe pain is what heralds rupture, and relief with position change points away from that emergency.

Correct Answer: "The screen reports a higher chance, not a diagnosis."

A screen produces a risk estimate rather than an answer. The nurse clarifies that the result raises her chance and that confirmation requires chorionic villus sampling or amniocentesis, which corrects the misunderstanding without false comfort. Option a is incorrect because blanket reassurance dismisses a real concern and may prove untrue. The client needs accurate information about what her number means, not a promise the nurse has no way of keeping. Option c is incorrect because agreeing with her turns a probability into a diagnosis she does not have. Most clients with a screen positive quad result carry an unaffected fetus, and discussing options now would be premature. Option d is incorrect because dismissing the test undermines her trust in the whole surveillance plan. False positives do occur, yet the result still earns genetic counseling, a detailed scan and an offer of diagnostic testing.

Correct Answer: "I will call right away if I see spots in my vision."

Scotomata and blurring signal cerebral involvement and belong on the call-immediately list along with an unrelenting headache, upper abdominal pain and sudden facial or hand swelling. Recognizing them early is what keeps her safe. Option a is incorrect because lying supine lets the uterus compress the vena cava and cut cardiac return. Rest is taken in a side-lying position, which also improves blood flow through the placenta. Option b is incorrect because tight rings mean fluid has leaked into the tissues, not that she is dry. Loading up on fluids pushes more volume into the interstitium and raises the risk of pulmonary edema. Option d is incorrect because self-treating that headache hides the very symptom the provider needs to hear about. A headache severe enough to wake her should prompt a phone call rather than another dose of analgesic.

Correct Answer: Emptying and recording the hourly urine volume

Measuring and recording output falls within the scope of assistive personnel. The nurse interprets the number, since magnesium continues about twenty-four hours after birth and an hourly volume under thirty milliliters means the drug is accumulating. Option a is incorrect because grading reflexes is an assessment requiring nursing judgment. The finding decides whether the infusion continues, so an unlicensed worker cannot be the one to detect that reflexes are fading. Option c is incorrect because adjusting a high-alert intravenous drug sits entirely outside unlicensed practice. Rate changes belong to the registered nurse working from provider orders, and errors with this medication can stop a client from breathing. Option d is incorrect because client education cannot be handed off to unlicensed staff. Explaining premonitory symptoms and what to report requires the knowledge base and accountability that belong to the licensed nurse alone.

Correct Answer: Continue the tracing and apply vibroacoustic stimulation

A quiet fetus is usually asleep, and sleep cycles run twenty to forty minutes. Extending the strip while an artificial larynx startles the fetus awake shortens the test and cuts the nonreactive rate. Option a is incorrect because a tracing without accelerations is a reason to look further, never a reason to deliver on its own. Most such strips belong to a sleeping fetus with normal oxygenation. Option b is incorrect because the label nonreactive is only earned after forty minutes of monitoring. Stopping at twenty minutes throws away the second half of a sleep cycle and would send this client for unnecessary testing. Option c is incorrect because lying flat compresses the vena cava and can turn a normal strip into a worrying one. Semi-Fowler's or a side-lying position protects maternal circulation throughout the study.

Correct Answer: Disseminated intravascular coagulation from the separation

Thromboplastin from the disrupted decidua sets off widespread clotting that consumes platelets and clotting factors. She clots and bleeds at the same time, which is why every puncture site weeps. Option b is incorrect because losing circulating volume produces tachycardia, cool skin, and falling pressure rather than bleeding from intact mucous membranes. Shock alone would not drop fibrinogen or scatter petechiae over her arm. Option c is incorrect because antibody formation against fetal cells develops silently over weeks and threatens a future pregnancy. It never produces oozing puncture sites or a collapsing clotting profile in the mother. Option d is incorrect because failing kidneys announce themselves through falling urine output and rising creatinine, not through gums that will not stop bleeding. Renal injury may follow later, but it explains none of these findings.

Correct Answer: "Come to the hospital now to be evaluated."

Preeclampsia and eclampsia can appear for the first time after birth, most often between two days and one week. This triad of unrelieved headache, visual change and new hand swelling needs evaluation without delay. Option a is incorrect because a dark room treats a migraine, and delaying by a day gives a seizure time to happen. Postpartum eclampsia strikes women who felt fine at discharge and went home unmonitored. Option b is incorrect because hormonal shifts do not blur vision or swell the hands. Calling these findings normal is precisely the error that lets late-onset disease progress to convulsion, stroke or pulmonary edema. Option d is incorrect because more analgesic masks the single symptom the provider most needs described. Extra fluid adds nothing either, since the swelling comes from leaking capillaries rather than from a shortage of water.

Correct Answer: "I should feel ten movements within two hours of counting."

The Cardiff method sets the target at ten movements within two hours, counted at the same time daily while lying quietly on her left side. Reaching that number is the reassuring endpoint she is watching for. Option a is incorrect because walking splits her attention and masks the smaller flutters. Counting asks for stillness in a quiet room, which is why the instruction pairs a consistent hour with lying on the side. Option c is incorrect because counting continues through the rest of pregnancy, not until some cutoff week. The last weeks carry the highest stillbirth risk, so stopping then would remove the surveillance exactly when it helps most. Option d is incorrect because hiccups come from a rhythmic reflex of the diaphragm and are excluded from the tally. Kicks, rolls, jabs and flutters are counted, and mistaking hiccups for them would inflate her total.