Custom: NSG 135 Exam #3 Spring 2025

Explanation

Explanation for the correct answer:
During pregnancy, it is normal for women to experience an increase in vaginal discharge, known as leukorrhea. This discharge is typically thin, white or milky, and odorless, and results from increased estrogen levels and vascularity of the vaginal mucosa. Therefore, a white, odorless discharge is not a cause for concern, and this statement indicates the client needs further teaching.

Why the other options are incorrect:

A. I should report any pain, burning, or itching associated with the vaginal discharge.
This is correct and shows appropriate understanding. These symptoms may indicate infection such as bacterial vaginosis or a yeast infection, which should be evaluated and treated during pregnancy.

B. I understand that an increase in vaginal discharge is normal during pregnancy.
This statement is accurate. Hormonal changes during pregnancy cause increased vaginal secretions, which serve to protect against ascending infections.

D. My vaginal walls may appear bluish due to increased blood flow.
This is a correct understanding. The bluish coloration of the vaginal walls is known as Chadwick's sign, a normal physiological change in early pregnancy due to increased vascularity.

Summary:

The correct answer is C. I should be concerned if I experience a white, odorless vaginal discharge, because this is a normal and expected change in pregnancy, not a warning sign. All other statements reflect an accurate understanding of normal physiological changes and appropriate symptom reporting during pregnancy.

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

C. Right upper quadrant pain
Right upper quadrant pain is a classic and most concerning sign of HELLP syndrome. This pain often results from liver distension due to hepatic involvement in HELLP syndrome, which can lead to liver rupture or hematoma formation, both of which are life-threatening complications for the mother. Prompt assessment and intervention are necessary when this symptom is present.

Why the Other Options Are Incorrect:

A. Blood pressure of 140/90 mmHg
While hypertension is a concern in pre-eclampsia and HELLP syndrome, a blood pressure of 140/90 mmHg is considered mildly elevated and is not as immediately concerning as right upper quadrant pain, which suggests hepatic involvement. However, hypertension should still be closely monitored.

B. Platelets 250,000/mm3
A platelet count of 250,000/mm3 is within the normal range (150,000–450,000/mm3). Thrombocytopenia (low platelets) is a hallmark of HELLP syndrome, but a count of 250,000/mm3 does not indicate a problem in this case.

D. Fetus expected weight for gestation
Although growth restriction is a concern in HELLP syndrome due to placental insufficiency, it is not the most immediate or concerning finding compared to right upper quadrant pain, which could indicate liver complications.

Summary:

The most concerning finding in this scenario is C. Right upper quadrant pain, as it is a sign of liver involvement in HELLP syndrome, which can lead to liver rupture or other severe complications. The other findings, while important, are not as immediately concerning in this context.

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

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. "A gain of about 25 to 35 pounds is recommended for you."
For a client with a normal BMI (18.5–24.9) prior to pregnancy, the recommended weight gain during pregnancy is typically between 25 and 35 pounds. This range is appropriate for the majority of women who start pregnancy at a healthy weight. This weight gain supports both the growing fetus and the mother’s increased blood volume, uterine size, and amniotic fluid.

Why the Other Options Are Incorrect:

A. "A gain of about 1 pound per week is recommended for you."
While 1 pound per week is a reasonable guideline for weight gain during the second and third trimesters, the total recommended weight gain over the course of pregnancy should be 25 to 35 pounds, not just a specific weekly gain. This answer doesn't provide the appropriate range for the entire pregnancy.

B. "A gain of about 15 to 25 pounds is recommended for you."
This recommendation is more applicable to overweight women or those who are slightly underweight before pregnancy. For a normal-weight woman, 25 to 35 pounds is typically the more accurate recommendation, as it accounts for the various physiological changes during pregnancy.

D. "A gain of about 30 to 40 pounds is recommended for you."
This weight gain range is typically recommended for underweight women or those carrying twins or multiple fetuses. For a normal-weight woman, this would be excessive and could increase the risk of complications like gestational diabetes or hypertension.

Summary:

The correct answer is C. "A gain of about 25 to 35 pounds is recommended for you." This is the general recommendation for a normal-weight woman during pregnancy, and it supports both maternal and fetal health. The other answers either underestimate or overestimate the appropriate weight gain for this client.

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

Explanation for the Correct Answers:

A. Provide a dark, quiet environment
Clients with severe gestational hypertension or severe preeclampsia may be at risk for seizures, so a dark, quiet environment helps to reduce stimuli and decrease the risk of neurologic irritability and seizures.

C. Administer magnesium sulfate IV
Magnesium sulfate is given to clients with severe gestational hypertension to prevent seizures. It helps to manage neurologic irritability and can be lifesaving for seizure prophylaxis.

D. Ensure that calcium gluconate is readily available
Calcium gluconate is the antidote for magnesium sulfate toxicity, which can cause respiratory depression and cardiac issues. It is critical to have it readily available in case of an overdose.

Why the Other Options Are Incorrect:

B. Assess respiratory status every 4 hr
Respiratory status should be assessed more frequently (typically every 1–2 hours) when the client is on magnesium sulfate, as magnesium sulfate toxicity can lead to respiratory depression. Every 4 hours is insufficient.

E. Evaluate neurologic status every 8 hr
Neurologic status should be evaluated more frequently (typically every hour or every 2 hours) for early signs of eclampsia or magnesium sulfate toxicity, not just every 8 hours.

Summary:

The correct answers are A. Provide a dark, quiet environment, C. Administer magnesium sulfate IV, and D. Ensure that calcium gluconate is readily available. These actions help manage severe gestational hypertension and prevent seizures. Frequent assessment of respiratory and neurologic status is necessary, so every 4 hours or every 8 hours is not adequate.

Explanation

Condition: Gestational diabetes mellitus (GDM)
The client has elevated fasting blood glucose (140 mg/dL) and HbA1c (10%), both of which are above normal limits, indicating poor glycemic control. The positive urine glucose and 3+ ketones further support GDM with possible ketosis, which increases risks for both maternal and fetal complications.

Actions to Take:

1. Perform a nonstress test (NST)
This assesses fetal well-being. Poor glycemic control in GDM can cause placental insufficiency, leading to fetal hypoxia or growth abnormalities. Regular NSTs help monitor for fetal distress.

2. Obtain daily fasting blood glucose levels
Frequent monitoring helps evaluate glycemic control and guides treatment (e.g., diet, insulin). Poor control increases risks for macrosomia, birth trauma, and neonatal hypoglycemia.

Parameters to Monitor:

1. Hemoglobin A1c
This gives an estimate of average blood glucose levels over the past 2–3 months. Monitoring trends helps assess long-term glucose control.

2. Urine specific gravity
This helps evaluate the hydration status, which is crucial especially with ketonuria and hyperglycemia, as dehydration can worsen maternal and fetal outcomes.

Why the Other Options Are Incorrect:

• Hyperemesis gravidarum would present with intractable vomiting, dehydration, and weight loss—not high glucose or HbA1c.
  
• Hypoglycemia would present with low blood glucose, not elevated.
  
• Phenylketonuria (PKU) is a rare metabolic disorder and unrelated to the current lab findings.
  
• Administering 15g of carbs is a treatment for hypoglycemia, not hyperglycemia.
  
• Teaching about PKU diet is not relevant here.
  

Summary:

The client is most likely experiencing gestational diabetes mellitus as indicated by elevated fasting glucose, high HbA1c, ketonuria, and glucosuria. The nurse should perform a nonstress test to monitor fetal well-being and obtain daily fasting glucose levels to guide management. Key parameters to monitor are Hemoglobin A1c and urine specific gravity for assessing both glycemic control and hydration status.