ATI RN
Complications in Early Pregnancy Questions
Question 1 of 5
A nurse has just completed an assessment on a client with mild pre-eclampsia. Which data indicate that her pre-eclampsia is worsening?
Correct Answer: A
Rationale: The correct answer is A (Blood pressure of 155/95) because an elevated blood pressure indicates worsening pre-eclampsia. In pre-eclampsia, high blood pressure is a key indicator of worsening condition, potentially leading to eclampsia or seizures if left untreated. Choices B (Urinary output is greater than 30 mL/hr), C (Deep tendon reflexes +2), and D (Client complains of blurred vision) are not indicative of worsening pre-eclampsia. Increased urinary output, normal deep tendon reflexes, and blurred vision are common symptoms in pre-eclampsia, but they do not necessarily signify worsening of the condition.
Question 2 of 5
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is because introducing objects into the vagina can potentially trigger preterm labor by causing infections or irritating the cervix. It is important to maintain vaginal hygiene to prevent complications. Choice A is incorrect as monitoring fetal movements is important but not directly related to preventing preterm labor. Choice C is incorrect as taking a stool softener is unrelated to preterm labor. Choice D is incorrect as decreasing fluid intake is not recommended and may lead to dehydration, which is detrimental during pregnancy.
Question 3 of 5
The nurse is providing discharge instructions to a 28-year-old client who received methotrexate for an ectopic pregnancy. Which should the discharge instructions include?
Correct Answer: C
Rationale: The correct answer is C. Methotrexate is a chemotherapy agent that can be harmful to others if not properly eliminated from the body. Instructing the client to flush the toilet twice after urination for the next 24 hours helps to reduce the risk of exposing others to the medication through urine. This precaution is important to prevent potential harm to others. Choices A, B, and D are incorrect: A: Taking folic acid is generally recommended to reduce side effects of methotrexate but is not directly related to the safety of others. B: While follow-up appointments are important, the immediate safety concern of methotrexate elimination is more critical. D: Resuming all activity in 48 hours may not be appropriate depending on the individual's response to methotrexate and their recovery process.
Question 4 of 5
A nurse is caring for a client who is 32 weeks gestation who comes to the emergency department for painful bleeding. Which is the priority nursing assessment?
Correct Answer: C
Rationale: The correct answer is C: Assess for hemorrhage. This is the priority assessment as the client is experiencing painful bleeding, indicating a potential hemorrhage which can be life-threatening. Assessing for hemorrhage will help identify the severity of the situation and guide immediate interventions. Monitoring for contractions (choice A) is important but assessing for hemorrhage takes precedence. Assessing pain level (choice B) is important but addressing the potential hemorrhage is more critical. Providing emotional support (choice D) is important but should come after addressing the urgent medical need of assessing for hemorrhage.
Question 5 of 5
The nurse is caring for a client with a suspected hydatidiform mole. Based on the diagnosis, what does the nurse anticipate? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Strong fetal heart tones. In a hydatidiform mole, the pregnancy is abnormal and does not involve a fetus. Therefore, the absence of fetal heart tones is expected. Dark brown vaginal bleeding (A) is not specific to a hydatidiform mole. Fundal height larger than expected (C) and elevated blood pressure (D) are not typically associated with a hydatidiform mole.