ATI RN
NCLEX Questions on Perinatal Loss Questions
Question 1 of 5
Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Anemia. During pregnancy, the maternal blood volume increases to support the growing fetus. This physiological hemodilution commonly leads to a mild decrease in red blood cells and hemoglobin levels, resulting in a state of relative anemia in pregnant individuals. Therefore, a 34-week gestation client would likely exhibit signs of anemia as a normal finding in their laboratory reports. Option B) Thrombocytopenia, a low platelet count, is not a normal finding in a 34-week gestation client. Thrombocytopenia can lead to an increased risk of bleeding, which is particularly concerning during childbirth. Option C) Polycythemia, an elevated red blood cell count, is also not a typical finding in a 34-week gestation client. Polycythemia can lead to complications such as increased blood viscosity, which may impair circulation and oxygen delivery to the fetus. Option D) Hyperbilirubinemia, an increase in bilirubin levels, is not expected in a 34-week gestation client. Hyperbilirubinemia is commonly associated with conditions like jaundice in newborns rather than pregnant individuals. Educationally, understanding the normal physiological changes that occur during pregnancy is crucial for nurses caring for pregnant clients. Recognizing what is considered normal versus abnormal helps in providing appropriate care and identifying potential complications promptly. This knowledge is especially important when interpreting laboratory reports and assessing the overall health status of pregnant clients.
Question 2 of 5
After a Preparation for Parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse's best action is to advise the client to do which of the following?
Correct Answer: B
Rationale: Rationale: The correct answer is B) Schedule an appointment at the clinic for an examination. The client's symptoms of yellow-gray frothy vaginal discharge and itching could indicate a possible infection, such as bacterial vaginosis or trichomoniasis, rather than a yeast infection. It is essential for the client's health and the health of the fetus to have a healthcare provider evaluate and diagnose the condition accurately. Option A) Using an over-the-counter cream for yeast infections is not appropriate in this case because the symptoms described are not typical of a yeast infection. Misdiagnosis and inappropriate treatment could lead to worsening of the condition. Option C) Administering a vinegar douche under low pressure is not recommended as it can disrupt the natural pH balance of the vagina and worsen the symptoms or even lead to further complications. Option D) Preparing for preterm labor and delivery is premature and not indicated based solely on the client's symptoms of vaginal discharge and itching. It is essential to rule out any infections or other underlying issues first before considering preterm labor. In an educational context, this question highlights the importance of accurate assessment and appropriate intervention in perinatal care. Nurses need to be vigilant in recognizing abnormal symptoms in pregnant clients and guiding them to seek proper medical evaluation and treatment to ensure the well-being of both the mother and the baby.
Question 3 of 5
The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station 2. Which of the following has the nurse palpated?
Correct Answer: A
Rationale: In this scenario, option A, "Thin cervix," is the correct answer. When the nurse palpates a thin cervix during a vaginal examination, it indicates cervical dilation. In the given scenario, the client is 5 cm dilated, which aligns with a thin cervix. Option B, "Bulging fetal membranes," is incorrect as this typically occurs when the client's water breaks, and the amniotic sac protrudes into the vaginal canal. Option C, "Head at the pelvic outlet," is incorrect because at station 2, the fetal head is not yet engaged in the pelvis but is still higher up in the birth canal. Option D, "Closed cervix," is incorrect as the scenario states the client is 5 cm dilated, so the cervix is not closed. Educationally, understanding the significance of findings during a vaginal examination in labor is crucial for nurses caring for laboring clients. It helps in assessing the progress of labor, determining the stage of labor, and making informed decisions regarding the client's care and possible interventions. Palpating and interpreting cervical dilation, effacement, and fetal station are key skills for nurses in providing safe and effective care during childbirth.
Question 4 of 5
A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
Correct Answer: C
Rationale: The correct answer is C) She may have a hidden laceration. In this scenario, the client's complaint of severe perineal pain despite receiving ibuprofen and the presence of edema suggest that there may be an underlying issue such as a hidden laceration that is causing the pain. It is crucial for the nurse to consider this possibility and further assess the client to rule out any complications that may require medical intervention. Option A) She should be assessed by her doctor is incorrect because the nurse should first assess the client herself to determine the cause of the pain before involving the doctor unnecessarily. Option B) She should have a sitz bath is incorrect as a sitz bath may provide comfort but it does not address the underlying issue of severe perineal pain that persists despite pain medication. Option D) She needs a narcotic analgesic is incorrect as the first step should be to investigate the cause of the pain rather than automatically escalating to a stronger pain medication. In an educational context, this question highlights the importance of thorough assessment and critical thinking in postpartum care. It emphasizes the need for nurses to consider all possible causes of a client's symptoms and to prioritize appropriate interventions based on assessment findings rather than jumping to conclusions or treatments. This scenario also underscores the significance of vigilance in detecting potential complications following childbirth, especially in cases where the client's symptoms are not improving as expected.
Question 5 of 5
A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Serial grip strengths. When a client is on magnesium sulfate therapy for severe preeclampsia, monitoring for signs of magnesium toxicity is crucial. Serial grip strength assessments are important because magnesium toxicity can lead to neuromuscular complications such as muscle weakness or loss of deep tendon reflexes. By assessing grip strength regularly, the nurse can detect these early signs of toxicity and intervene promptly to prevent further complications. Option B) Kernig assessments are used to assess for meningitis, not magnesium sulfate toxicity. Option C) Pupillary responses are important for assessing neurological status but are not specific to monitoring magnesium toxicity. Option D) Apical heart rate checks are important for monitoring cardiac function but do not specifically indicate magnesium toxicity. Educational context: Understanding the signs and symptoms of magnesium sulfate toxicity is essential for nurses caring for clients with severe preeclampsia. By regularly assessing grip strength, nurses can identify early signs of magnesium toxicity and prevent serious complications. This knowledge and skill are critical for providing safe and effective care to perinatal clients at risk for complications related to hypertension in pregnancy.