1 PRENATAL PERIOD
271. A rubella titer result of a 1-day postpartum client is less than 1: 8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. ** 3. The vaccine is administered by the subcutaneous route. ** 4. Exposure to immunosuppressed individuals needs to be avoided. ** 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. ** 6. The area of the injection needs to be covered with a sterile gauze for 1 week.
271. 2, 3, 4, 5 Rationale: Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.
265. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery
1. A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations
270. A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps? 1. "Bend your foot toward your body while flexing the knee when the cramps occur." 2. "Bend your foot toward your body while extending the knee when the cramps occur." 3. "Point your foot away from your body while flexing the knee when the cramps occur." 4. "Point your foot away from your body while extending the knee when the cramps occur."
2. "Bend your foot toward your body while extending the knee when the cramps occur." Leg cramps occur when the pregnant client stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Options 1, 3, and 4 are not measures that provide relief from leg cramps.
268. A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 1. "The procedure takes about 2 hours." 2. "It will be necessary to drink 1 to 2 quarts of water before the examination." 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." 4. "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture."
3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 4 identify components of abdominal ultrasound.
275. The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? 1. Increase in pulse rate 2. Increase in blood pressure 3. Frequent bowel elimination 4. Decrease in red blood cell production 2
1. Increase in pulse rate Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/ minute, which then persists to term. Options 2, 3, and 4 are incorrect. During pregnancy, the blood pressure usually is the same as the prepregnancy level, but then gradually decreases up to about 20 weeks of gestation. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus. During pregnancy, there is an accelerated production of red blood cells.
264. The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? 1. Normal 2. Abnormal 3. The need for further evaluation 4. That findings were difficult to interpret
1. Normal A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 beats/ minute) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 beats/ minute must occur, each with a duration of at least 15 seconds, in a 20-minute intervalS
267. A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest? 1. Swimming 2. Scuba diving 3. Low-impact gymnastics 4. Bicycling with the legs in the air
1. Swimming Non- weight-bearing exercises are preferable to weight-bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non- weight-bearing exercises such as swimming are allowable.
272. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."
2. "I need to lie flat on my back to perform the procedure." The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify her health care provider if she feels fewer than 10 kicks over two, 2-hour intervals or as instructed by her HCP.
263. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately." 4. "Use tampons if the discharge is bothersome, but to be sure to change the tampons every 2 hours."
2. "The vaginal discharge may be bothersome, but is a normal occurrence." Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently
274. The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 1. Avoid wearing a bra. 2. Wash the breasts with warm water and keep them dry. 3. Wear tight-fitting blouses or dresses to provide support. 4. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.
2. Wash the breasts with warm water and keep them dry. The pregnant client should be instructed to wash the breasts with warm water and keep them dry. The client should be instructed to avoid using soap on the nipples and areolar area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses cause discomfort. The client is instructed to wear soft-textured clothing to decrease nipple tenderness and to use breast pads inside the bra to prevent leakage through the clothing if colostrum is a problem.
262. The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure. 2. Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.
3. An informed consent needs to be signed before the procedure. Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in a health care provider's private office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.
266. A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? 1. Hematocrit 38% 2. Glucose 86 mg/ dL 3. Hemoglobin 9.1 g/ dL 4. White blood cell count 12,400 cells/ mm3
3. Hemoglobin 9.1 g/ dL Pica practices often lead to iron deficiency anemia, resulting in a decreased hemoglobin level. The laboratory values in options 1, 2, and 4 are normal for the pregnant client.
273. The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? 1. "I should avoid straining during bowel movements." 2. "I can gently replace the hemorrhoids into the rectum." 3. "I can apply ice packs to the hemorrhoids to reduce the swelling." 4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."
4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the discomfort from hemorrhoids.
276. The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. "I should avoid between-meal snacks." 2. "I should lie down for an hour after eating." 3. "I should use spices for cooking rather than using salt." 4. "I should avoid eating foods that produce gas and fatty foods."
4. "I should avoid eating foods that produce gas and fatty foods." Lying down is likely to lead to reflux of stomach contents, especially immediately after a meal. The client should be instructed to avoid spices, along with salt, because spices trigger heartburn. Salt produces edema. The client should be encouraged to eat between-meal snacks and should be instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating three large meals. The client also should limit or avoid gas-producing and fatty foods.
269. The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. "I should wear panty hose." 2. "I should wear support hose." 3. "I should wear flat nonslip shoes that have good support." 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."
4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours." Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize falls.
