Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area?

Correct Answer: C

Rationale: The correct answer is C: 3. A score of 3 in edema assessment indicates significant edema in the lower extremities, face, hands, and sacral area. This score reflects a higher level of pitting edema, which is commonly observed in these areas in cases of fluid retention. Scores 1 and 2 are typically used to indicate mild to moderate edema in specific areas or generalized mild edema, not as extensive as described in the question. Score 4 would typically indicate severe edema involving not only the mentioned areas but also potentially other body parts. Therefore, choice C is the most appropriate answer based on the extent and distribution of edema described in the question.

Correct Answer: B

Rationale: The correct answer is B because Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. During pregnancy or birth, some fetal Rh-positive blood may enter the mother's bloodstream, leading to the production of Rh antibodies. These antibodies can then cause complications in future pregnancies if the fetus is Rh-positive again. Choices A, C, and D are incorrect because Rh incompatibility specifically involves the Rh factor of the fetus, not the mother's own Rh status, the father's Rh status, or both being Rh-negative.

Correct Answer: A

Rationale: The correct answer is A: Determining cervical dilation and effacement. This assessment is contraindicated for a patient with suspected placenta previa because it can lead to further disruption of the placenta and potentially cause severe bleeding. Monitoring FHR and vital signs (B) is important for assessing fetal well-being and maternal status. Observing vaginal bleeding or amniotic fluid leakage (C) is crucial in identifying complications. Determining the frequency, duration, and intensity of contractions (D) is essential for monitoring labor progression but is not appropriate for a patient with suspected placenta previa due to the risk of placental disruption.

Correct Answer: A

Rationale: The correct answer is A: Hemorrhage is the primary concern. In an ectopic pregnancy, the fertilized egg implants outside the uterus, typically in the fallopian tube, which can lead to life-threatening internal bleeding. Nursing care focuses on monitoring for signs of hemorrhage, such as abdominal pain, vaginal bleeding, and signs of shock. Prompt intervention is crucial to prevent serious complications. Explanation of why the other choices are incorrect: B: She will be unable to conceive in the future - This statement is not true as having an ectopic pregnancy does not necessarily impact future fertility. C: Bed rest and analgesics are the recommended treatment - Bed rest and analgesics are not the primary treatments for ectopic pregnancy, as surgical intervention is often necessary. D: A D&C will be performed to remove the products of conception - A D&C is not typically performed for ectopic pregnancy management, as it involves the removal of tissue from inside the uterus, not the fallopian

Correct Answer: A

Rationale: The correct answer is A: immediate birth is required. The positive Kleihauer–Betke test indicates fetal-maternal hemorrhage, where fetal blood enters the maternal circulation. This can lead to fetal-maternal transfusion, causing fetal anemia. Immediate birth is necessary to assess and manage potential fetal distress, such as anemia and hypoxia, due to the trauma from the MVA. Choices B, C, and D are incorrect: B: Transferring to critical care unit is not the immediate priority. The focus should be on addressing the fetal distress. C: RhoGAM is given to Rh-negative mothers to prevent Rh sensitization, but it is not directly related to the positive Kleihauer–Betke test result. D: Tetanus shot administration is important for tetanus prevention, but it is not the priority in this case where immediate birth is required due to fetal-maternal hemorrhage.