Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae.
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.

The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:

b. Uterine tenderness.

Here's why:

• Hypertension (a):While preeclampsia can increase the risk of abruptio placenta,it's not always present,and hypertension wouldn't be the immediate expected finding during the abruption event itself.
• Fetal tachycardia (c):This can occur in early stages of abruption to compensate for decreased oxygen supply,but as the abruption becomes more severe,fetal bradycardia is more likely due to oxygen deprivation.
• Leukorrhea (d):This is a white vaginal discharge and has no connection to abruptio placenta.

Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:

• Vaginal bleeding (bright red or dark)
• Abdominal pain or cramping
• Sudden, ongoing uterine tightening or irritability
• Fetal distress (decreased fetal heart rate movements)

Therefore, option b is the most expected finding in this scenario.

Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.

Choice A rationale:
Human papillomavirus vaccine is not typically administered during pregnancy.
Choice B rationale:
Rubella vaccine is a live vaccine and is generally contraindicated during pregnancy.
Choice C rationale:
Tetanus vaccine is safe and recommended during pregnancy.
Choice D rationale:
Varicella is a live vaccine and is generally contraindicated during pregnancy.

Choice A rationale:
A depressed anterior fontanel is not typically caused by forceps-assisted birth. It can indicate dehydration or intracranial pressure.
Choice B rationale:
Uneven gluteal skinfolds could suggest developmental dysplasia of the hip, not a forceps injury.
Choice C rationale:
Epicanthal folds are a normal characteristic in many populations and are not related to birth injuries.
Choice D rationale:
Facial asymmetry can occur due to pressure from the forceps on the facial nerves during delivery.

Choice A rationale:
Breast tenderness is a common side effect of oral contraceptives and does not need immediate medical attention.
Choice B rationale:
Persistent headaches can be a sign of a serious side effect such as a stroke or blood clot and should be reported immediately.
Choice C rationale:
Vaginal itching could be a sign of a yeast infection, but it’s not typically associated with oral contraceptives.
Choice D rationale:
Painful intercourse could be due to various reasons, but it’s not a common side effect of oral contraceptives.

Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.

Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labor.
Choice B rationale:
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal, which may require immediate attention.
Choice C rationale:
A sense of excitement and warm, flushed skin are normal emotional and physiological responses during labor.
Choice D rationale:
Progressive sacral discomfort during contractions is a normal part of labor as the baby descends through the birth canal.

Choice A rationale:
Yellow exudate will form at the surgical site in 24 hours, which is a normal part of the healing process.
Choice B rationale:
A dark red appearance of the penis could indicate a complication such as infection or necrosis, which would require medical attention.
Choice C rationale:
The Plastibell is not removed manually; it falls off naturally within 5 to 8 days.
Choice D rationale:
A snug diaper could cause pressure and discomfort on the surgical site; it’s recommended to fasten the diaper loosely.

The Plastibell circumcision technique is one of the most common methods of newborn circumcision. It involves placing a plastic ring under the foreskin and tying a suture around it to cut off blood flow. The foreskin then falls off naturally with the ring in seven to 10 days.

The correct answer is A. The nurse should include that “yellow exudate will form at the surgical site in 24 hours” as part of the teaching to the parents. This is because the yellow exudate is a normal sign of healing and should not be confused with infection.

The other options are incorrect because:

b. The parents should notify the provider if the end of the baby’s penis appears black, not dark red. This could indicate that the ring is too tight and is cutting off blood supply to the glans.
c. The Plastibell will not be removed 4 hours after the procedure. It will stay on the penis until the foreskin falls off naturally in seven to 10 days.
d. The newborn’s diaper should be loose, not snug. This is to prevent the ring from being dislodged or rubbing against the diaper.

Choice A rationale:
Changing the perineal pad once daily could lead to infection, which would delay wound healing.
Choice B rationale:
Witch hazel pads are often used for their soothing and anti-inflammatory properties, which can aid in healing.
Choice C rationale:
Cleaning the perineum with a squeeze bottle after urinating helps to keep the area clean and promote healing.
Choice D rationale:
A well-approximated suture line indicates that the wound edges are close together, which is conducive to healing.

Choice A rationale:
Breastfeeding is not contraindicated following rubella immunization, so this statement is incorrect.
Choice B rationale:
The rubella vaccine is a single-dose vaccine, not a series of three.
Choice C rationale:
Joint pain can occur following rubella immunization, but it’s not a severe side effect that requires immediate medical attention.
Choice D rationale:
Women are advised to avoid pregnancy for at least 1 month following rubella immunization due to the theoretical risk to the fetus, so this statement is correct.

Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.

Choice A rationale:
Uterine hypertonicity is associated with labor complications, not placenta previa.
Choice B rationale:
A persistent headache is not a typical symptom of placenta previa.
Choice C rationale:
A firm, rigid abdomen is a sign of a possible uterine rupture, not placenta previa.
Choice D rationale:
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is correct.

Choice A rationale:
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice B rationale:
Applying pressure on the client’s suprapubic area is not part of the McRoberts maneuver. However, when coupled with suprapubic pressure, the effectiveness of the McRoberts maneuver increases to 90%1.
Choice C rationale:
Moving the client onto their hands and knees is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Choice D rationale:
Applying pressure to the client’s fundus is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.

Choice A rationale:
Turning the newborn every 4 hours is not necessary during phototherapy. The aim of phototherapy is to expose the newborn’s skin to as much light as possible.
Choice B rationale:
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The aim of phototherapy is to expose the newborn’s skin to as much light as possible.
Choice C rationale:
Eye covers should be used to protect the newborn’s eyes from the light during phototherapy.
Choice D rationale:
Providing the newborn with 15 mL glucose water after each feeding is not necessary during phototherapy. The newborn may need to be fed more often to help get rid of the bilirubin in his or her bowel movements.

Choice A rationale:
Replacing the infant’s identification band after his name has been recorded is not a recommended practice for newborn identification.
Choice B rationale:
Checking the newborn’s identification using the crib card is not a recommended practice for newborn identification.
Choice C rationale:
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is a reliable method of identification of the newborn.
Choice D rationale:
Requiring visitors to wear an identification band is not a recommended practice for newborn identification.

Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.

The correct answer is 0.5 tablet(s). Calculation: The client needs 250 mg per dose, and each tablet is 500 mg. So, 250 mg (required dose) divided by 500 mg (tablet strength) equals 0.5 tablets.

Choice A rationale:
Misoprostol is not typically used for preeclampsia management. It’s used for cervical ripening and labor induction.
Choice B rationale:
Assessing for edema is important in a client with preeclampsia as it can indicate a worsening condition.
Choice C rationale:
Restricting daily oral fluid intake is not typically part of the management plan for preeclampsia without severe features.
Choice D rationale:
Administering an IV bolus of lactated Ringer’s is not typically part of the management plan for preeclampsia without severe features.

Choice A rationale:
Magnesium sulfate does not increase cardiac output. It is a central nervous system depressant and muscle relaxant.
Choice B rationale:
Magnesium sulfate is given to clients with preeclampsia to prevent seizures, which can be a complication of this condition.
Choice C rationale:
Magnesium sulfate does not directly stabilize the fetal heart rate. Its primary use in preeclampsia is seizure prevention.
Choice D rationale:
While magnesium sulfate can cause vasodilation, which could improve tissue perfusion, its primary use in preeclampsia is to prevent seizures.

Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.

Choice A rationale:
Freezing embryos for future use is a personal decision and not something a nurse should instruct a client to avoid.
Choice B rationale:
In vitro fertilization can result in multiple pregnancies, and reduction of multiple fetuses may be necessary for the health of the mother and the remaining fetuses.
Choice C rationale:
The use of donor oocytes is a personal decision and not something a nurse should instruct a client to avoid.
Choice D rationale:
In in vitro fertilization, sperm is introduced to the egg in a laboratory, not the uterus.

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

• Subtract 3 months from June 21, which gives you March 21.
• Add 7 days to March 21, which gives you March 28.
• Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.

Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.

Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.