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: Correct Answer: A Rationale: A blood pressure of 155/95 indicates hypertension, a key feature of worsening pre-eclampsia. Hypertension in pre-eclampsia can lead to serious complications like eclampsia. High blood pressure can put the client at risk for seizures, stroke, and organ damage. Incorrect choices: B: Urinary output > 30 mL/hr is a positive sign, indicating adequate renal function, which is desirable in pre-eclampsia. C: Deep tendon reflexes +2 are within normal limits and do not necessarily indicate worsening pre-eclampsia. D: Blurred vision is a common symptom of pre-eclampsia but not a definitive sign of worsening 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 important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.
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: Flush the toilet twice after she urinates for the next 24 hours. Methotrexate is excreted in urine and can be harmful if it comes into contact with others. Flushing the toilet twice helps to minimize the risk of exposure to others. Choice A is incorrect because although folic acid supplementation may be necessary with methotrexate, it is not the priority in this scenario. Choice B is incorrect as the client should be advised to seek immediate medical attention if any concerning symptoms occur, rather than waiting for 6 weeks. Choice D is incorrect as the client needs to avoid certain activities for a period of time after receiving methotrexate to prevent complications.
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 priority nursing assessment in this scenario is to assess for hemorrhage (Choice C). This is crucial because painful bleeding in a client at 32 weeks gestation could indicate a potential life-threatening situation such as placental abruption or placenta previa. Assessing for hemorrhage involves checking the amount and type of bleeding, vital signs, and signs of shock. It is essential to identify and address hemorrhage promptly to prevent adverse outcomes for both the mother and the baby. Monitoring for contractions (Choice A) is important but assessing for hemorrhage takes precedence due to the immediate risk it poses. Assessing the pain level (Choice B) is secondary to assessing for hemorrhage in this case. Providing emotional support (Choice D) is important but should come after ensuring the client's physical well-being is addressed.
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: Step-by-step rationale: 1. Hydatidiform mole is a type of gestational trophoblastic disease. 2. It results in the abnormal growth of placental tissue instead of a fetus. 3. As there is no fetus, there won't be any fetal heart tones. 4. Therefore, the nurse anticipates absence of fetal heart tones. Summary: A: Dark brown vaginal bleeding is not specific to hydatidiform mole. C: Fundal height larger than expected is not a typical sign of hydatidiform mole. D: Elevated blood pressure is not directly associated with hydatidiform mole.