Sample NCLEX about Obstetrics Nursing (86-90)

--> Sample NCLEX about Obstetrics Nursing

86.A nurse is reviewing the physician's orders for a client admitted for premature rupture of membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician's order should the nurse question?

a) perform a vaginal examination every shift
b) monitor maternal vital signs every 4 hours
c) monitor fetal heart rate (FHR) continuously
d) administer ampicillin 1gm as an intravenous piggyback (IVPB) every 6 hours

87. A nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following nursing diagnosis would be most appropriate for this client at this time?

a) fear
b) fatigue
c) powerlessness
d) ineffective coping

88. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

a) infection
b) hemorrhage
c) chronic hypertension
d) disseminated intravascular coagulation

89. A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with DIC?

a) prolonged clotting times
b) decreased platelet count
c) swelling of the calf of one leg
d) petechiae, oozing from injection sites, and hematuria

90. A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

a) a soft abdomen
b) uterine tenderness
c) absence of abdominal pain
d) painless, bright red vaginal bleeding





Sample NCLEX about Obstetrics Nursing
ANSWERS AND RATIONALE

86) A
- vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor maternal vital signs, and monitor the FHR.

87) A
- the mother is anxious and frightened, and the most appropriate nursing diagnosis for the client at this time is fear. No data in the question support a nursing diagnosis of powerlessness, ineffective coping, or fatigue, although these nursing diagnoses may be considered for this client at some point during the hospitalization experience.

88) B
- because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. Option A, C, and D are not risks that are related specifically to placenta previa.

89) C
- disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process, coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petichiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely associated with thrombophlebitis.

90) B
- painless, bright red vaginal bleeding in the second trimester of pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitor often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding

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