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Questions 158

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Question 1 of 5

A first-trimester primigravida is diagnosed with anemia. The nurse should suspect that this anemia is a result of:

Correct Answer: A

Rationale: Increased maternal blood volume in the first trimester causes dilutional anemia due to a relative decrease in red blood cell concentration.

Question 2 of 5

The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?

Correct Answer: B

Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.

Question 3 of 5

The client is admitted with a diagnosis of molar pregnancy. Which nursing intervention is most appropriate?

Correct Answer: A

Rationale: Molar pregnancy involves abnormal trophoblastic tissue not a viable fetus and can cause significant vaginal bleeding. Monitoring for bleeding is the most appropriate intervention. Cesarean delivery tocolytics and fetal monitoring are not indicated.

Question 4 of 5

On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

Correct Answer: B

Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.

Question 5 of 5

The client is admitted with a diagnosis of abruptio placenta. Which complication is most likely to occur?

Correct Answer: C

Rationale: Abruptio placenta causes placental separation leading to fetal distress (from hypoxia) and maternal hemorrhage (from bleeding). Both are common and serious complications.

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