Page 716 - Saunders Comprehensive Review For NCLEX-RN

reviews the plan of care and prepares to monitor the client for which risk
associated with placenta previa?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation
223. The nurse is performing an assessment on a client diagnosed with placenta
previa. Which assessment findings should the nurse expect to note? Select
all that apply.
1. Uterine rigidity

2. Uterine tenderness

3. Severe abdominal pain
4. Bright red vaginal bleeding

5. Soft, relaxed, nontender uterus

6. Fundal height may be greater than expected for gestational

age

Answers

204. Answer: 1

Rationale: Perinatal transmission of HIV can occur during the antepartum period,
during labor and birth, or in the postpartum period if the mother is breast-feeding.
Clients who have HIV will most likely be advised not to breast-feed; however,
PHCPs recommendations regarding breast-feeding are always followed. There is no
physiological reason why the newborn needs to be fed by nasogastric tube.
Test-Taking Strategy: Use knowledge regarding the transmission of HIV.
Eliminate options 3 and 4 first because these options are comparable or alike in that
they both address breast-feeding. From the remaining options, select the correct
option, knowing that it is unnecessary to feed the newborn by nasogastric tube.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Maternity: Postpartum
Health Problem: Maternity: Infections/Inflammations
Priority Concepts: Client Education; Infection
Reference: McKinney et al. (2018), pp. 567-568.

205. Answer: 4

Rationale: If the client complains of a headache and blurred vision, the PHCP
should be notified because these are signs of worsening preeclampsia. Options 1, 2,
and 3 are normal findings.

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