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Repositioning the mother Documenting the finding Correct Notifying the nurse-midwife Taking the mother's vital signs Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal movement. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother’s vital signs are all unnecessary actions. Test-Taking Strategy: Examine the fetal monitor tracing and see that itshows accelerations. Recalling that the presence of accelerations indicates fetal well-being will direct you to the correct option. Review the significance of accelerations on fetal monitoring if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 393, 395). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Awarded 0.0 points out of 1.0 possible points. 53. ID: 383702973 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? Nausea Bloody urine Hearing loss Correct Electrocardiographic changes Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity. Test-Taking Strategy: Focus on the subject, an adverse effect. This question may be difficult to answer unless you have some specific knowledge regarding cisplatin. Remember that this chemotherapeutic agent causes ototoxicity. Review the adverse effects of cisplatin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2010 (p. 243). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Awarded 0.0 points out of 1.0 possible points. 54. ID: 383709219 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? Painful vaginal bleeding Sustained tetanic contractions Complaints of abdominal pain Soft, relaxed, nontender uterus Correct Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetratesthe myometrium, resulting in uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis, placenta previa. It is easy to confuse placenta previa and abruption; remember that the difference involves the presence of uterine pain and tenderness with an abruption, versus painless bleeding and a soft, relaxed, and nontender uterus with placenta previa. Review the difference between placenta previa and placental abruption if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 614, 615). St. Louis: Elsevier. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Intrapartum Awarded 0.0 points out of 1.0 possible points. 55. ID: 383706609 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placentalseparation has occurred? A discoid uterus Sudden sharp vaginal pain Shortening of the umbilical cord A sudden gush of dark blood from the introitus Correct Rationale: Placentalseparation occurs when the placenta separatesfrom the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual. Test-Taking Strategy: Use the process of elimination and focus on the subject, placentalseparation. Try visualizing this physiological process as a means of finding the correct option. Review the signs of placental separation if you had difficulty with this question. Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., pp. 376, 377). St. Louis: Mosby. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment