Custom: NSG 135 Exam #3 Spring 2025

Explanation

The correct answer is:

B. Weeks 1-12

Explanation for the correct answer:

• The first trimester of pregnancy is from weeks 1 to 12. This is the period when the embryo develops into a fetus, and major organ systems begin to form. The first trimester is critical for fetal development and is often the time when a client may experience early pregnancy symptoms, such as nausea, fatigue, and frequent urination.
  

Why the other options are incorrect:

• A. Weeks 25-36:
  
  • This timeframe falls within the third trimester of pregnancy, not the first trimester. The third trimester is typically from weeks 28 to 40, but 25-36 would specifically refer to the later part of the second trimester and into the third.
    
• C. Weeks 13-24:
  
  • These weeks represent the second trimester, not the first. The second trimester spans weeks 13 to 26 and is the time when many women experience relief from early pregnancy symptoms and the fetus continues to grow.
    
• D. Weeks 37-40:
  
  • These weeks correspond to the third trimester, which involves the final stages of fetal development and preparation for labor.
    

Correct Answer Is:

The first trimester is from weeks 1 to 12 of pregnancy, during which crucial development of the fetus occurs.

Explanation

Correct answer: A. "This medication promotes softening of the cervix."

Explanation:

• A. "This medication promotes softening of the cervix":
  
  • Dinoprostone gel is a prostaglandin used to ripen the cervix in preparation for labor. It helps in softening, dilating, and effacing the cervix to facilitate labor. This is the correct purpose of dinoprostone in prenatal care.
    

Why the other options are incorrect:

• B. "This medication is used to treat preeclampsia":
  
  • Dinoprostone is not used to treat preeclampsia. Preeclampsia is typically managed with antihypertensive medications, magnesium sulfate, and possibly delivery. Dinoprostone is used for cervical ripening and induction of labor, not for preeclampsia.
    
• C. "It causes relaxation of the uterine muscles":
  
  • Dinoprostone does not primarily cause relaxation of the uterine muscles. It is used to promote cervical ripening and initiate labor, but it does not relax the uterine muscles. Medications like tocolytics (e.g., terbutaline) are used to relax the uterine muscles in preterm labor.
    
• D. "It is used to treat genital herpes simplex virus":
  
  • Dinoprostone is not used to treat genital herpes simplex virus. The treatment for genital herpes typically involves antiviral medications (e.g., acyclovir), not cervical ripening agents like dinoprostone.
    

Correct Answer Is:

Dinoprostone gel is used to soften the cervix and promote cervical changes to help initiate labor. It does not treat preeclampsia, herpes, or cause uterine muscle relaxation.

Explanation

The correct answer is:

B. Placenta previa

Explanation for the Correct Answer:

B. Placenta previa

• Placenta previa occurs when the placenta is positioned low in the uterus and covers or is near the cervix. It is characterized by painless, bright red vaginal bleeding in the second or third trimester, which matches the client’s symptoms (recent onset of bright red vaginal bleeding without uterine contractions or tenderness). The absence of uterine tenderness and normal fetal heart rate also points towards placenta previa.
  

Why the Other Options are Incorrect:

A. Preterm labor

• Preterm labor is associated with regular uterine contractions, cervical changes, and sometimes vaginal bleeding. The client does not have uterine contractions, which makes preterm labor less likely in this case.
  

C. Placental abruption

• Placental abruption involves the premature separation of the placenta from the uterine wall, which typically presents with painful, dark red vaginal bleeding and uterine tenderness. The client’s presentation, which includes a soft, non-tender uterus, does not align with this condition.
  

D. Vasa previa

• Vasa previa occurs when fetal blood vessels cross or run near the cervical os, which can lead to fetal bleeding and fetal distress during labor. It is often accompanied by sudden, severe fetal heart rate decelerations, which are not present in this case. Also, the bleeding in vasa previa is typically associated with labor or rupture of membranes.
  

Correct Answer Is:

The most likely condition based on the client's symptoms (bright red vaginal bleeding without uterine tenderness or contractions and normal fetal heart rate) is B. Placenta previa.

Explanation

Explanation for the correct answer:
The first priority when a prolapsed umbilical cord is observed is to relieve pressure on the cord to preserve fetal oxygenation. Inserting a gloved hand into the vagina and gently lifting the presenting fetal part off the cord helps restore and maintain blood flow through the umbilical vessels, preventing fetal hypoxia and death. This is the immediate, life-saving action the nurse must perform before any other interventions.

Why the other options are incorrect:

A. Place the client in knee-chest position
This is a secondary action that helps reduce pressure on the cord by using gravity to shift the fetus upward. However, it does not directly and immediately relieve compression of the cord like manual elevation does. Therefore, it should be done after inserting a gloved hand to relieve pressure.

B. Prepare the client for an immediate birth
Although an emergency cesarean section is likely necessary, preparing the client comes after immediate life-saving measures are taken. The fetus must first be protected from hypoxia by relieving pressure on the cord.

C. Cover the cord with a sterile, moist saline dressing
This action helps maintain cord viability and prevent drying if the cord is protruding outside the vaginal canal, but it does not address the life-threatening compression. It is important but not the first priority.

Summary:

The correct answer is D. Insert a gloved hand into the vagina to relieve pressure on the cord. This is the first and most critical intervention to prevent fetal hypoxia in a prolapsed umbilical cord. While other actions such as repositioning, covering the cord, and preparing for birth are important, they should follow the immediate manual relief of cord compression.

Explanation

The correct answer is:

D. Persistent vomiting that prevents fluid intake

Explanation for the correct answer:

• Persistent vomiting that prevents fluid intake is a warning sign that can indicate hyperemesis gravidarum, a condition that may cause dehydration, electrolyte imbalance, and weight loss. It is a more severe form of nausea and vomiting during pregnancy and requires medical attention to prevent complications for both the mother and fetus.
  

Why the other options are incorrect:

• A. Increased urination, especially at night
  
  • Increased urination, especially at night, is a common and normal symptom in pregnancy, particularly in the first trimester. It is typically due to hormonal changes and increased blood flow to the kidneys. It does not require calling the clinic unless it is associated with other symptoms like pain or burning.
    
• B. Occasional mild headaches relieved with rest
  
  • Mild headaches are common in the first trimester due to hormonal changes, increased blood volume, and changes in blood pressure. If headaches are mild and relieved by rest, they are not typically a cause for concern. However, persistent or severe headaches may require further evaluation.
    
• C. Breast tenderness and enlargement
  
  • Breast tenderness and enlargement are normal symptoms in the first trimester due to hormonal changes in pregnancy. These symptoms are generally not alarming and are part of the physiological changes the body undergoes in preparation for lactation.
    

Correct Answer Is:

Persistent vomiting that prevents fluid intake is a serious concern and could indicate hyperemesis gravidarum, which requires medical intervention. The other symptoms listed, while uncomfortable, are typically normal in the first trimester and do not warrant immediate concern.

Explanation

The correct answer is:

B. Initiate IV access.

Explanation for the correct answer:

• The client is at 38 weeks of gestation and presenting with large amounts of painless, bright red vaginal bleeding, which is suggestive of placenta previa, a condition where the placenta is located near or over the cervix. The absence of uterine contractions and a normal fetal heart rate (138/min) are reassuring but do not eliminate the potential risk to the mother or fetus from excessive bleeding.
  
• The priority nursing action is to initiate IV access to prepare for potential blood loss. It is essential to ensure that the client has a secure intravenous line to administer fluids, medications, or blood products if necessary.
  
• The low blood pressure (98/52 mm Hg) and elevated heart rate (118/min) may indicate early signs of hypovolemia (low blood volume) due to the bleeding, so the nurse should act swiftly to manage and prevent further complications.
  

Why the other options are incorrect:

• A. Insert an indwelling urinary catheter:
  
  • While inserting a catheter may be necessary later if the client is being prepared for surgery, it is not the priority at this time. The immediate concern is stabilizing the client with IV access to manage potential blood loss.
    
• C. Witness the signature for informed consent for surgery:
  
  • Informed consent is important, but the immediate action should focus on stabilizing the client and ensuring IV access in case surgical intervention becomes necessary. The consent form should be witnessed after stabilizing the client.
    
• D. Prepare the abdominal and perineal areas:
  
  • This may be necessary if the client progresses to requiring surgical intervention, such as a cesarean section. However, the immediate priority is to stabilize the client first, which includes securing IV access for fluids or blood products.
    

Correct Answer Is:

The priority nursing action is to initiate IV access to prepare for managing the potential consequences of bleeding and stabilize the client, as they are at risk for hypovolemia.

Explanation

C. "Ambivalent feelings are quite common for women early in pregnancy."
It is normal for women in the first trimester of pregnancy to experience ambivalent feelings, which can include doubts, anxiety, and second thoughts. Pregnancy brings significant life changes, and it is common for a woman to feel uncertain or conflicted about these changes early on. Acknowledging these feelings as common provides emotional support and helps the client feel understood and not isolated in her experience.

Why the Other Options Are Incorrect:

A. "Perhaps you should see a counselor to discuss these feelings further."
While counseling may be helpful if the feelings persist or worsen, it is premature to suggest counseling as the first step. The nurse should first reassure the client that ambivalence is common during pregnancy and that these feelings often resolve as the pregnancy progresses.

B. "Have you spoken to your mother about these feelings?"
While discussing feelings with family members can sometimes be helpful, this suggestion might seem dismissive. It does not directly address the client’s emotional state and may make her feel pressured to talk to someone specific instead of validating her feelings.

D. "Don't worry. You will be fine once the baby is born."
This response minimizes the client’s feelings and suggests that they should not be addressed. It also implies that the client will automatically feel better after the baby is born, which is not guaranteed. It is important to validate the client’s feelings rather than dismissing them with reassurances that may not resonate.

Summary:

The correct response is C. "Ambivalent feelings are quite common for women early in pregnancy." This approach validates the client’s feelings and reassures her that her experience is typical and understandable, while also offering an opportunity for further discussion if needed. The other responses do not adequately acknowledge the emotional complexity that can occur during early pregnancy.

Explanation

Correct answer: C. Observe for crowning.

Explanation:

• C. Observe for crowning:
  
  • The fetal head at 3+ station is descending through the birth canal. As the head descends further and reaches the perineum, crowning will occur, where the head becomes visible at the vaginal opening. This is a key sign of impending delivery and indicates that the birth is imminent. The nurse should be prepared for this moment and be ready to assist with the birth.
    

Why the other options are incorrect:

• A. Apply fundal pressure:
  
  • Fundal pressure is contraindicated during the second stage of labor, especially when the fetal head is descending. Applying pressure to the fundus can cause harm to both the mother and the fetus. It is generally not recommended unless in specific emergencies like shoulder dystocia, but not in normal labor at this stage.
    
• B. Observe for the presence of a nuchal cord:
  
  • While it is important to be aware of the possibility of a nuchal cord (cord around the neck), it is not the priority at 3+ station unless there are signs of fetal distress or abnormal findings. The nurse would typically check for a nuchal cord during the delivery or if the fetal heart rate is concerning.
    
• D. Prepare to administer oxytocin:
  
  • Oxytocin is used to augment or induce labor, but the client is already in active labor with the fetal head at 3+ station. There is no indication that oxytocin is necessary in this case unless there are concerns about the progress of labor, such as inadequate contractions. However, the labor is progressing, so oxytocin is unnecessary at this point.
    

Correct Answer Is:

At 3+ station, the nurse should observe for crowning, which indicates that the birth is near. Monitoring for crowning helps the nurse be prepared for the imminent delivery of the baby.

Explanation

The correct answer is:

B. Slightly above the umbilicus

Explanation for the correct answer:

• Fundal height is a useful indicator of fetal growth and development during pregnancy. At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus. The general rule is that the fundal height, in centimeters, corresponds approximately to the gestational age in weeks, give or take 2 cm. Therefore, at 22 weeks, the fundus is expected to be around 22 cm from the pubic symphysis, which typically places it slightly above the umbilicus.
  

Why the other options are incorrect:

• A. Slightly below the umbilicus:
  
  • At 22 weeks of gestation, the fundus should not be located below the umbilicus. It would typically be higher, closer to the umbilicus or slightly above it, depending on the individual client.
    
• C. 3 cm below the umbilicus:
  
  • This is not accurate for a 22-week pregnancy. At this stage, the fundus would be at or just above the level of the umbilicus, not below it.
    
• D. 3 cm above the umbilicus:
  
  • While it’s possible for the fundus to be slightly above the umbilicus at 22 weeks, a measurement of 3 cm above would be more typical at a later gestational age, closer to 24–26 weeks. At 22 weeks, the fundus would typically be just slightly above the umbilicus, not 3 cm.
    

Correct Answer Is:

At 22 weeks of gestation, the fundus should be palpated slightly above the umbilicus, which is consistent with the general rule that fundal height should be approximately equal to the gestational age in weeks.