306 Ricci Chapter 12: Nursing Management During Pregnancy

A pregnant client reports occasional headaches. She wants to know what she can take to alleviate the discomfort. What would be the best response by the nurse?

"The safest medication to take for your headaches during your pregnancy would be acetaminophen." The medication that is approved for the treatment of headaches in pregnant women is acetaminophen.

A client at 10 weeks' gestation is complaining of ptyalism over the past 2 weeks. What intervention would the nurse recommend to this client? Select all that apply.

Chew gum. Suck on hard candies. Ptyalism or excess salivation may be relieved by chewing gum or sucking on hard candies. Many of the interventions used to relieve nausea and vomiting may also work for ptyalism.

A pregnant client reports chewing on ice throughout the day. Which laboratory value would the nurse evaluate?

serum iron level Pregnant clients who crave ice often have an iron deficiency. A low serum iron level needs to be checked. The client's electrolyte values are not associated with cravings for ice.

Untreated hyperemesis can lead to preterm birth. What is the cause of the preterm birth?

severe dehydration resulting in hypoperfusion of the placenta With severe dehydration there is hypoperfusion to the placenta, and preterm labor may be initiated. Ketonuria impacts the fetus' neurologic development but does not initiate preterm labor. Medications used to control nausea and vomiting do not induce labor.

In preparing for a preconception class, the nurse plans to include a discussion of potential risk factors. Which risk factor would be most important to include?

the use of OTC drugs with teratogens Risk factors for adverse pregnancy have been demonstrated by statistics gathered for smoking during pregnancy, consuming alcohol during pregnancy, not taking adequate folic acid supplements during pregnancy, being obese, taking prescription or OTC drugs that are known teratogens, and having a preexisting condition that can negatively affect pregnancy if unmanaged.

The nurse is conducting a prenatal class for a group of primigravida clients. Which instruction will the nurse prioritize when teaching about breast care?

wash the nipples with clean water only She should use only clean water to wash the nipples. The use of any soap will dry the nipples and can lead to cracking.

The client's pregnancy screening test shows that the maternal serum alpha-fetoprotein (MS-AFP) level is high. Which information should the nurse provide the client upon this finding?

"A high level of MS-AFP is associated with neural tube defects. We will schedule you for another type of test to determine if your baby has a neural tube defect." High levels of MS-AFP indicate an increased risk of a neural tube defect and need to be followed up with a diagnostic test. Low levels of MS-AFP are an indicator of increased risk for Down syndrome. The level of MS-AFP is not associated with, or predictive of, preterm labor. A fetal fibronectin test is used to predict risk for preterm labor.

The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best?

"At 36 weeks gestation, the fundus is in the normal expected location" The fundus grows to reach the umbilicus at 20 to 22 weeks and the xiphoid process of the sternum at 36 weeks. Therefore, this fundus is in the normal, expected location. After 36 weeks' gestation, lightening occurs and the fundus will drop ~4 cm below the xiphoid process. Once the fundus reaches the xiphoid process, it cannot go higher without severely compromising maternal respiratory efforts.

A nurse is educating a prenatal client at her second visit. The client is worried about "blotchy brown spots" on her forehead. The nurse reassures the client about this change by giving which appropriate response?

"Avoid sun because it will make the discoloring darker" Increased estrogen levels during pregnancy can cause pigmentation to increase. This discoloration is not harmful and will eventually fade; however, sunlight can make it darker. Bleaching is not an appropriate suggestion. The nurse should not tell the client that the discoloration is permanent or a sign of cancer.

The nurse is providing care for a pregnant client who has been given the necessary requisitions for laboratory work by the primary care provider. The client notices that the lab tests include testing for HIV and other sexually transmitted infections, and expresses alarm, stating, "I don't understand why the doctor would suspect that I've got these diseases." What is the nurse's most therapeutic statement?

"Every pregnant client is tested for these diseases; it doesn't necessarily suggest that the doctor suspects that you have them." The nurse should reassure the client that these lab tests are ordered for all clients, not only those who are at high risk for sexually transmitted infections. Making general statements about the incidence of sexually transmitted infections or the need for thorough care does not address the client's expressed concern.

A client with a prepregnant BMI of 26 is concerned about gaining weight during pregnancy. Which statement by the client indicates an appropriate goal for this pregnancy?

"I need to consume at least 1500 nutrient dense calories each day" An overweight client needs at least 1,500 calories per day. Choosing nutrient-dense calories helps to limit excessive weight gain. Carbohydrates are needed for energy. Small, frequent meals help to maintain a constant blood glucose level and decrease binge eating. While the growing fetus needs nutrients, the fetus does not burn excessive calories ingested by the mother.

A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching?

"I should substitute intercourse with nonsexual touch to avoid harming the fetus" Sexual needs may be met through sexual intercourse with a partner as long as the pregnancy is healthy and there are no other risk factors, such as bleeding or rupture of membranes. Pregnancy is a time of a heightened need for touch, which may be met partially by sexual expression, but which can also be met through nonsexual touch, such as massage, caressing, or holding.

A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching?

"I wear knee highs rather than pantyhose" Women with varicosities should not wear knee-high stockings as they put pressure on leg veins and reduce venous return.

At 24 weeks' gestation a client is asked to drink a sweet orange solution and then wait an hour to have blood drawn. The client asks if this is the test to determine if she has diabetes. What is the best response by the nurse?

"This is a screening procedure. If your result is elevated you will be scheduled for a longer test to determine if you have gestational diabetes." A glucose tolerance test involves a glucose load and a blood glucose level 1 hour later. It is a screening test used to determine if the client needs a full 3-hour oral glucose tolerance test. A 1-hour glucose tolerance test is not diagnostic of insulin resistance nor gestational diabetes. If the screening test is elevated the client is scheduled for the diagnostic test at approximately 24 to 26 weeks' gestation. If a client is eventually diagnosed with gestational diabetes, the initial treatment is diet therapy, not insulin.

When providing preconception care to a client, which instruction will the nurse to provide about medications during pregnancy?

"You need to talk with your health care provider about using all prescription, over-the-counter, and herbal medications." Medication use is common during pregnancy, with prevalence estimates generally exceeding 65% and increasing over the years. Pregnant women use a wide variety of both prescription and over-the-counter medications for both pregnancy-related conditions and conditions unrelated to pregnancy conditions. Little is known about the effects of taking most medications during pregnancy. It is best for pregnant women to not take any medications during their pregnancy. At the very least, they should be encouraged to discuss with the health care provider their current medications and any herbal remedies they take so that they can learn about any potential risks should they continue to take them during pregnancy. A common concern of many pregnant women involves the use of over-the-counter medications and herbal agents. Many women consider these products benign simply because they are available without a prescription. Although herbal medications are commonly thought of as "natural" alternatives to other medicines, they can be just as potent as some prescription medications. The nurse should encourage pregnant women to check with their health care providers before taking anything.

A pregnant client presents for her first prenatal visit. She informs the nurse that she had an ectopic pregnancy 3 years ago. She ask the nurse if this would happen this time. Which response by the nurse would be best?

"Your statistical risk of another tubal pregnancy is increased" If a woman has had tubal/ectopic pregnancy, her statistical risk of another tubal pregnancy is increased. The other comments are not therapeutic and do not supply accurate information or address the client's legitimate concerns.

The diagonal conjugate of a pregnant woman's pelvis is measured. Which measurement would the nurse interpret as presenting a potential problem?

12.0 cm The diagonal conjugate, usually 12.5 cm or greater, indicates the anteroposterior diameter of the pelvic inlet. The diagonal conjugate is the most useful measurement for estimating pelvic size because a misfit with the fetal head occurs if it is too small.

A client who is in her first trimester is anxious to have an ultrasound at each visit. The nurse explains that it is not necessary and schedules a second ultrasound to be performed when she is about:

18-20 weeks pregnant There are no hard-and-fast rules as to how many ultrasounds a woman should have during her pregnancy; however, the first ultrasound is usually performed during the first trimester to confirm the pregnancy. A second scan may be performed at about 18 to 20 weeks' to look for congenital malformations. A third one may be done at around 34 weeks' to evaluate fetal size and verify placental position.

The nurse assesses a 20-week gestational client at a routine prenatal visit. What will the nurse predict the fundal height to be on this client experiencing an uneventful pregnancy?

20 cm Between weeks 18 and 32 the fundal height in centimeters should match the gestational age of the pregnancy. At 20 weeks' the fundal height should be at the umbilicus. A fundal height smaller than expected can indicate that the original dates were miscalculated, oligohydramnios, or that the fetus is smaller than expected. If the fundal height is larger than expected this can indicate multiple gestation, the original dates were miscalculated, polyhydramnios, or a molar pregnancy.

The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age? 2

20 weeks Some clients will not seek early prenatal care, especially if it is not their first pregnancy. The uterus expands to reach the height of the umbilicus by week 20. Before week 20 it is too low to be palpated, and after week 20 it may be beyond the umbilicus.

The nurse is reviewing client data following a regular monthly appointment at 6 months' gestation. Which fundal height requires no further intervention?

24 cm An anticipated fundal height for 24 weeks' gestation (6 months) is 24 cm. Between 18 and 32 weeks' gestation, the fundal height in centimeters should match the gestational age. All of the other measurements would require further intervention.

At the first prenatal visit of all clients who come to the clinic appropriate blood screenings are obtained. The nurse realizes that an HgbA1C above which level is concerning for diabetes and warrants further testing?

6.5% A hemoglobin A1C level of at least 6.5% is concerning for overt diabetes, and further testing should be conducted to ensure the client is not diabetic. If glucose testing is not diagnostic of overt diabetes, the woman should be tested for gestational diabetes from 24 to 28 weeks' gestation with a 75-gm oral glucose tolerance test.

At the first prenatal visit of all clients who come to the clinic appropriate blood screenings are obtained. The nurse realizes that an HgbA1C above which level is concerning for diabetes and warrants further testing?

6.5% A hemoglobin A1C level of at least 6.5% is concerning for overt diabetes, and further testing should be conducted to ensure the client is not diabetic. If glucose testing is not diagnostic of overt diabetes, the woman should be tested for gestational diabetes from 24 to 28 weeks' gestation with a 75-gm oral glucose tolerance test.

The nurse is scheduled to see four clients. Which client is at highest risk for depression?

A 17-year-old at 32 weeks' gestation, living with a 22-year-old man who is not the father of her baby, because her parents made her move out when she got pregnant Risk factors for depression are young age, lack of social support, and unintended pregnancy. A young client with the support of her partner and her parents is at less risk. Similarly, women in their 20's with resources such as a job and health insurance, a planned pregnancy as well as support of their partner and family are also at lower risk for depression.

At the first prenatal visit, the client reports her last menstrual period (LMP) was November 16. The nurse determines the estimated due date to be:

August 23 There are several methods to determine the estimated date of birth. Naegele rule can be used, which involves subtracting 3 months and then adding 7 days to the first day of the LMP. Then correct the year by adding 1 where necessary. Another method is to add 7 days and then add 9 months and add 1 to the year where needed. Thus the client reports her LMP was November 16 subtract 3 months (August), add 7 days (23), and adjust the year by adding 1 year. This client's estimated date of birth is August 23, in the following year.

At 32 weeks' gestation a client with a BMI of 23 has gained 24 lb (11 kg). What is the nurse's recommendation for weight gain for the remainder of this pregnancy?

Continue to gain approximately 1 lb (.45 kg) per week during this pregnancy. Expected weight gain is 1.5 lb (0.68 kg) per month in the first trimester and 1 lb (.45 kg) per week for the second and third trimester. This client needs to continue to gain 1 lb (.45 kg) per week. Restricting weight gain near the end of pregnancy can negatively impact fetal growth.

The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is:

December 30 Using Naegele rule, since the first day of the client's last menstrual period is March 23, 7 days are added leading to the 30th. Subtracting 3 months from March is December. Thus, December 30 is the estimated date of delivery.

The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is:

December 30 Using Naegele rule, since the first day of the client's last menstrual period is March 23, 7 days are added leading to the 30th. Subtracting 3 months from March is December. Thus, December 30 is the estimated date of delivery.

A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply.

Establish a baseline of present health. Determine the gestational age of the fetus. Monitor for fetal development and maternal well-being. Identify women at risk for complications. The purposes of prenatal care are to establish a baseline of present health; determine the gestational age of the fetus; monitor fetal development and maternal well-being; identify women at risk for complications and minimize the risk of possible complications; and provide time for education about pregnancy, lactation, and newborn care. It is not done to help a clinic financially.

A woman relates to the nurse that she understands that dietary fat is bad for her and that she should avoid it during pregnancy. How should the nurse respond?

Fats are essential during pregnancy, and vegetable oils are a good source. Omega-3 fatty acids, particularly linoleic acid, are fats that are essential for new cell growth but cannot be manufactured by the body. Vegetable oils such as safflower, corn, olive, peanut, and cottonseed, fatty fish, omega-3 infused eggs, and omega-3 infused spreads are all good sources. Pregnant women should ingest between 200 and 300 mg daily. Because some fish may be contaminated by mercury, alert women that the American Pregnancy Association (APA) recommends that marlin, orange roughy, tilefish, swordfish, shark, king mackerel, and bigeye and ahi tuna should be avoided during pregnancy.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of spontaneous abortion (miscarriage) within the first trimester. The nurse is correct to document the history as:

G = 3, T = 1, P = 0, A = 1, L = 1 The GTPAL stands for Gravida -- number of pregnancies, which is 3 (current, 4-year-old, and miscarriage); Term -- only one pregnancy thus far carried to term; Preterm deliveries -- 0; Abortions (including miscarriages) -- 1; Living children -- 1. Do not be distracted by the twins. That is still one pregnancy.

A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history?

G3 P0020 Gravida (G) is the total number of pregnancies she has had, including the present one. Therefore she is G3 and not G2. Para (P), the outcome of her pregnancies, is further classified by the FPAL system as follows: F = Full term: number of babies born at 37 or more weeks of gestation, which is 0 and not 1 in this case. P = Preterm: number of babies born between 20 and 37 weeks of gestation, which is 0 in this case. A = Abortions: total number of spontaneous and elective abortions, which is 2 in this case. L = Living children, as of today. She has no living children; therefore, it is 0 and not 1.

A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history?

G3, T0, P1, A1, L1 The woman's obstetric history would be documented as G3, T0, P1, A1, L1. G (gravida) = 3 (past and current pregnancy), T (term pregnancies) = 0, P (number of preterm pregnancies) = 1, A (number of pregnancies ending before 20 weeks viability to include miscarriage) = 1, and L (number of living children) = 1.

A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn? Select all that apply.

Limit consumption of food before bedtime. Sleep in a semi-Fowler position. Avoid overeating. When caring for a pregnant client with heartburn, the nurse should instruct the client to limit consuming foods before bedtime. The nurse should also instruct the client to sleep in a semi-Fowler position and to avoid overeating. The nurse need not instruct the client to avoid the use of antacids. On the contrary, antacids are known to be useful for heartburn even during pregnancy. The nurse should not instruct the client to consume lots of fluids before bedtime. Along with food, even fluids should be limited before bedtime.

A woman reports that her last menstrual period (LMP) occurred February 1, 2017. Using the Naegele rule, what would be her estimated date of delivery (EDD)?

November 8, 2017 To determine the due date using Naegele rule, add 7 days to the date of the first day of the LMP, and then subtract 3 months.

The client is 32 weeks' pregnant and has been referred for a biophysical profile (BPP) after a nonreassuring nonstress test (NST). Which statement made by the client indicates that the nurse's explanation of the procedure was effective?

The BPP is an ultrasound that measures breathing, body movement, tone and amniotic fluid volume A biophysical profile uses a combination of factors to determine fetal well-being based upon five fetal biophysical variables. An NST is done to measure FHR acceleration. Then an ultrasound is done to measure breathing, body movements, tone, and amniotic fluid volume. Each variable receives a score from 0 to 2 for a maximum score of 10. A score of 6 or less indicates altered fetal well-being and indicates a need for further assessment. A needle is not involved with the BPP. The BPP does not detect placental problems, and the BPP is not a screening for neural tube defects.

A client in the third trimester of pregnancy has to travel a long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client?

always wear a three point seatbelt To promote easy and safe travel for the client, the nurse should instruct the client to always wear a three-point seat belt to prevent ejection or serious injury from collision. The nurse should instruct the client to deactivate the air bag if possible. The nurse should instruct the client to apply a nonpadded shoulder strap properly, ensuring that it crosses between the breasts and over the upper abdomen, above the uterus. The nurse should instruct the client to use a lap belt that crosses over the pelvis below—not over—the uterus.

A client in the third trimester of pregnancy has to travel a long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client?

always wear a three-point seatbelt To promote easy and safe travel for the client, the nurse should instruct the client to always wear a three-point seat belt to prevent ejection or serious injury from collision. The nurse should instruct the client to deactivate the air bag if possible. The nurse should instruct the client to apply a nonpadded shoulder strap properly, ensuring that it crosses between the breasts and over the upper abdomen, above the uterus. The nurse should instruct the client to use a lap belt that crosses over the pelvis below—not over—the uterus.

The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure?

amniocentesis Amniocentesis is an invasive procedure whereby a needle is inserted into the amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with Rh(D)-negative blood, since the puncture can allow the seepage of blood and amniotic fluid into the woman's system. She should receive Rho(D) immune globulin after the procedure to protect her and future babies. The CST, NST, and a biophysical profile are noninvasive tests.

The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure?

amniocentesis Amniocentesis is an invasive procedure whereby a needle is inserted into the amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with Rh(D)-negative blood, since the puncture can allow the seepage of blood and amniotic fluid into the woman's system. She should receive Rho(D) immune globulin after the procedure to protect her and future babies. The CST, NST, and a biophysical profile are noninvasive tests.

A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function?

amniotic fluid volume A biophysical profile combines five parameters (fetal reactivity, fetal breathing movements, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment. The fetal heart and breathing record measures short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.

The nurse understands that the maternal uterus should be at what location at 20 weeks' gestation?

at the level of the umbilicus By 20 weeks' gestation, the uterus is at about the level of the umbilicus; by 36 weeks, it nears the bottom of the sternum.

A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location?

at the umbilicus At 20 weeks, the fundus can be palpated at the umbilicus. A fundus of 12 weeks' gestation is palpated at the symphysis pubis. At 16 weeks' gestation, the fundus is midway between the symphysis pubis and umbilicus. At 36 weeks' gestation, the fundus can be palpated just below the ensiform cartilage.

What instruction should a nurse offer to a pregnant client or a client who wishes to become pregnant to help her avoid exposure to teratogenic substances?

avoid medications The nurse should instruct a client who is pregnant or one who wants to conceive to avoid medications and thus avoid exposure to any kind of teratogenic substance. Eating a well-balanced diet and maintaining personal hygiene, though important during pregnancy, will not prevent a client's exposure to teratogenic substances. Coffee is not a teratogenic substance, so the client need not avoid coffee. However, coffee is not recommended during pregnancy because it may increase the risk of spontaneous abortion (miscarriage).

Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth. The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

between 24 and 28 weeks gestation Screening for gestational diabetes is best done between 24 and 28 weeks' gestation, unless screening is warranted in the first trimester for high-risk reasons. If the initial screening is elevated, then further testing should be conducted to confirm the diagnosis.

A nurse is reading a journal article about the use of real-time ultrasonography, which allows the health care provider to obtain information about the fetus. The nurse would expect the article to describe which type of information?

biophysical profile A biophysical profile uses real-time ultrasound to allow assessment of various parameters of fetal well-being. This may include fetal movements, fetal tone, and fetal breathing, as well as assessment of amniotic fluid volume with or without assessment of fetal heart rate. Chromosomal abnormalities are detected via amniocentesis. Neural tube defect treatment is not evaluated via biophysical profile, and although the placenta may be observed, it is not the focus of this procedure.

Which possible complication associated with back pain can lead to premature contractions?

bladder or kidney infection Obtaining a detailed account of a woman's back symptoms is crucial because back pain can be an initial sign of a bladder or kidney infection. Increased ICP, spinal fluid leak, and a herniated disc are usually not associated with back pain during a normal pregnancy.

A pregnant client reports being unable to find snacks at work. Which snacks would the nurse recommend she prepare in advance to take to work? Select all that apply.

carrot sticks cheese and crackers Carrots sticks and cheese and crackers are nutrient-dense snacks. Pretzels and mustard, doughnuts and juice, and a candy bar with almonds all have a high calorie-to-nutrient ratio.

The nurse is teaching about an iron supplement that the client is going to take every day. The nurse teaches the client to take the iron supplement with which type of fluid?

citrus juice The citric acid in juice enhances absorption of iron in the GI tract. Ice water and tea do not enhance iron absorption, and milk can inhibit iron absorption.

A woman calls the prenatal clinic and says that she thinks she might be in labor. She shares her symptoms over the phone with the nurse and asks what to do. The nurse determines that she is likely in true labor and that she should head to the hospital. Which symptom is an indicator of true labor?

contractions beginning in the back and sweeping forward across the abdomen True labor contractions usually begin in the back and sweep forward across the abdomen similar to tightening of a rubber band. They gradually increase in frequency and intensity over a period of hours. Lightening and intermittent backache are preliminary signs of labor but do not indicate true labor. Increase in fetal kick count does not indicate true labor.

Which disease process would the nurse screen for under potential genetic disorders?

cystic fibrosis Screening of genetically linked disorders is important when obtaining a family history. Cystic fibrosis is a genetically linked disorder. Tuberculosis is an infectious disorder. Rheumatic fever stems from a streptococcus infection. Asthma is a hypersensitivity typically from an environmental allergy.

When teaching a client about nutrition during pregnancy, the nurse should include which long-term outcomes in the plan of care? Select all that apply.

developing healthy patterns for a lifetime identifying foods to build iron stores incorporating foods to build bone mass designing a diet consistent with cultural factors During pregnancy, teaching includes healthy nutrition for the pregnancy, such as building iron stores and bone mass as well as developing healthy patterns for a lifetime; this impacts both the client and her future children. Any teaching about nutrition needs to be consistent with cultural factors. These are long-term outcomes. Finding inexpensive sources of low-fat foods is not consistent with healthy teaching during pregnancy.

The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate?

document this and continue to monitor the murmur at future visits Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal.

A client in the first trimester reports having nausea and vomiting, especially in the morning. Which instruction would be most appropriate to help prevent or reduce the client's compliant?

eat dry crackers or toast before rising The nurse should recommend the client eat dry crackers or toast before rising to prevent nausea and vomiting in the morning. Drinking plenty of fluids at bedtime could cause nocturia. Foods such as cheese should be avoided to prevent constipation. Spicy foods could cause heartburn.

A client at 28 weeks' gestation is asking for a laxative for constipation. What action would the nurse recommend?

eat fiber rich foods Increasing dietary fiber is the best way to address constipation. Laxatives, suppositories, and enemas only provide temporary relief and may stimulate labor.

A woman who is 4 months pregnant has pyrosis. Which suggestion would the nurse give her?

eat small meals and do not lie down after meals Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the stomach causes regurgitation into the esophagus. Eating small meals and remaining upright limits the possibility of regurgitation.

When counseling a lacto-ovo-vegetarian client, the nurse would recommend including which source of protein in the diet during pregnancy?

eggs Lacto-ovo-vegetarians eat no animal flesh or fish, but they do eat dairy products, so eggs are a source of protein. Brown rice is not a source of protein.

A nurse is assessing a client's nutritional intake during pregnancy. What is the best method for accomplishing this?

enacting a 24-hour nutritional recall Although all of the answers refer to interventions that the nurse should include in her assessment, the 24-hour nutrition recall is the best single method for assessing her nutritional intake.

Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management?

episodes of double vision Difficulty with vision can occur from cerebral edema or is a symptom of hypertension of pregnancy.

A client presents with a positive home pregnancy test. The client has a 7-month-old baby and a 2-year-old child with her. What is a priority assessment to be completed during this visit?

evaluation of nutrition status Clients with pregnancies close together are at risk for entering pregnancy with nutrient deficiencies because there is not adequate time to rebuild nutrient stores.

The nurse is describing pregnancy danger signs to a pregnant woman who is in her first trimester. Which danger sign might occur at this point in her pregnancy?

excessive vomiting Excessive vomiting is a warning sign in the first trimester. Dyspnea, lower abdominal pressures, and swelling of face or extremities may occur late in pregnancy.

A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which information?

further testing will be required to confirm any diagnosis Nursing management related to marker screening tests consists primarily of providing education about the tests. Remind the couple that a definitive diagnosis is not made without further tests such as an amniocentesis. The blood tests are not definitive but only strongly suggest the possibility of a defect. For some conditions there are no treatments. The couple may request a second set, but the health care provider will probably suggest proceeding with the more definitive methods to confirm the diagnosis. `

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider. Which signs and symptoms would the nurse include? Select all that apply.

headache with visual changes in the third trimester sudden leakage of fluid during the second trimester lower abdominal pain with shoulder pain in the first trimester Danger signs and symptoms that need to be reported immediately include headache with visual changes in the third trimester; sudden leakage of fluid in the second trimester; and lower abdominal pain accompanied by shoulder pain in the first trimester. Urinary frequency in the third trimester, nausea and vomiting during the first trimester, and backache during the second trimester are common discomforts of pregnancy.

The nurse is teaching a pregnant client some nonpharmacologic ways to handle common situations encountered during pregnancy. The nurse determines the session is successful when the client correctly chooses which condition that can be minimized if she avoids drinking fluids with her meals?

heartburn Filling the stomach with heavy food and fluid can cause overfill and place pressure on the stomach, increasing gastric reflux. Avoid excess fluids with meals and eat small frequent meals to avoid heartburn. Nosebleeds result from increased estrogen. Blood clots can result from sitting still for too long. Constipation can result from increased progesterone.

A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her?

heath seeking behaviors related to ways to relieve discomforts of pregnancy Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.

When caring for a client with lactose intolerance, the nurse would be aware of which potential problem during pregnancy?

inadequate calcium for skeletal growth Lactose intolerance can lead to inadequate calcium intake, which can impact fetal skeletal growth. There are many nondairy sources of protein. Iron and folate intake are not altered by lactose intolerance.

A 28-year-old client who has just conceived arrives at a health care facility for her first prenatal visit to undergo a physical examination. Which intervention should the nurse perform to prepare the client for the physical examination?

instruct the client to empty her bladder When preparing the client for a physical examination, the nurse should instruct the client to empty her bladder; the nurse should then collect the urine sample so that it can be sent for laboratory tests to detect possibilities of a urinary tract infection. The client need not lie down, take deep breaths, or have the family present; however, it is important for the nurse to ensure that the client feels comfortable.

An adolescent at 8 weeks' gestation is at her first prenatal visit. During the health history interview, the nurse asks the client, "Are you afraid of anyone?" What is the nurse assessing with this question?

intimate partner violence Pregnant women, especially adolescents, are at increased risk for intimate partner violence. The nurse needs to ask enough questions to be certain that the woman is not experiencing physical, sexual, or emotional intimate partnership violence.

Why is a Papanicolaou test done at the first prenatal visit?

it identifies abnormal cervical cells A Pap test is a test for cervical cancer. Should abnormal cells be present, the woman may need to make a decision about her priorities of therapy for cervical disease or continuing the pregnancy.

A pregnant client in her third trimester is diagnosed with supine hypotension syndrome. What would the nurse instruct the client to do?

lie laterally, preferably on the left side The nurse should instruct the client to lie laterally, preferably on the left side, to enhance uteroplacental perfusion. Sleeping on a hard mattress, using a hot water bag, and performing mild exercises are ineffective in relieving this condition.

Nausea and vomiting are common reports during pregnancy. What nutritional action can be used to lessen nausea and vomiting?

limiting intake of heavy, greasy foods Nausea and vomiting can be lessened by limiting intake of fatty and greasy foods and eating small frequent meals every 2 to 3 hours. Other interventions include eating carbohydrate foods such as dry crackers, Melba toast, dry cereal, or hard candy before getting out of bed in the morning. Avoid drinking liquids with meals; avoid coffee, tea, and spicy foods; and eliminate individual food intolerances. Drinking liquids, increasing fluid intake, and limiting carbohydrate intake does not lessen nausea and vomiting.

Nausea and vomiting are common reports during pregnancy. What nutritional action can be used to lessen nausea and vomiting?

limiting intake of heavy, greasy foods Nausea and vomiting can be lessened by limiting intake of fatty and greasy foods and eating small frequent meals every 2 to 3 hours. Other interventions include eating carbohydrate foods such as dry crackers, Melba toast, dry cereal, or hard candy before getting out of bed in the morning. Avoid drinking liquids with meals; avoid coffee, tea, and spicy foods; and eliminate individual food intolerances. Drinking liquids, increasing fluid intake, and limiting carbohydrate intake does not lessen nausea and vomiting.

The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse anticipate being used to evaluate the fetus for potential neural tube defects?

maternal serum alpha-fetoprotein analysis Alpha-fetoprotein is a substance produced by the fetus. AFP enters the maternal circulation by crossing the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus. The optimal time for AFP screening is 16 to 18 weeks. The triple marker screens for AFP, hCG, and unconjugated estriol. This screens for neural defects and Down syndrome. The Doppler flow study evaluates the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for chromosomal defects.

The nurse is assessing a client at 14 weeks' gestation at a routine prenatal visit and notes the fundal height is at the umbilicus. The nurse will most likely interpret this finding to indicate which situation?

multiple fetal pregnancy The fundus typically is at the level of the umbilicus at 20 weeks' gestation. Therefore the fundal height is greater than that which is expected, suggesting possible multiple gestation, polyhydramnios, fetal anomalies, or macrosomia. Smaller than expected measurements would suggest intrauterine growth retardation or possibly inadequate amount of amniotic fluid. Urinary retention would displace the uterus.

A nurse is educating a pregnant client about physical changes that can occur in pregnancy. Which conditions are associated with physical changes in pregnancy? Select all that apply.

nasal stuffiness and sinus problems thoracic breathing instead of abdominal breathing swollen and tender gums During pregnancy, the respiratory system changes to increase lung volume for the fetus. This change can increase estrogen and cause nasal congestion and sensitive, swollen gums. When the fetus is growing, the thoracic muscles and cartilage relax more, and breathing becomes thoracic as the chest broadens. Persistent cough and Kussmaul respirations are not related to pregnancy.

A woman who is pregnant for the first time has arrived to the labor department thinking she was in labor only to be diagnosed with Braxton Hicks contractions and sent home. Prior to leaving the unit, the woman asks, "How will I know when it is 'true' labor?" Which signs/symptoms should the woman associate with true labor? Select all that apply.

pain in back that wraps across the abdomen and increases in frequency and intensity pink-tinged blood and mucus mixture on underwear sudden gush of clear fluid coming from the vagina True labor contractions usually begin in the back and sweep forward across the abdomen similar to the tightening of a rubber band. They gradually increase in frequency and intensity over a period of hours. As the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy is expelled. The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus. This blood, mixed with mucus, takes on a pink tinge and is referred to as "show" or "bloody show." Labor may begin with rupture of the membranes, experienced either as a sudden gush or as a scanty, slow seeping of clear fluid from the vagina. Leaking colostrum from the nipples can occur throughout the pregnancy. Occasionally, a woman notices urinary incontinence (involuntary loss of urine on coughing or sneezing) during pregnancy.

During the initial prenatal visit, the nurse performs what assessment to guide teaching about nutrition during pregnancy?

prepregnancy BMI Weight gain goal during pregnancy is based on the client's prepregnant BMI. Current weight and height are part of the BMI calculation. Hemoglobin level only provides information about iron stores, not overall nutritional status.

A nurse is caring for a client who is 8 months pregnant. Which instruction is the nurse most likely to give her?

rest on the left side for at least 1 hour in the morning and afternoon During the last months of pregnancy, the nurse should instruct the woman to rest on her left side for at least 1 hour in the morning and afternoon. This position relieves fetal pressure on the renal veins, helps the kidneys excrete fluid, and increases flow of oxygenated blood to the fetus. The body's oil and sweat glands are more active than usual during pregnancy. Thus, a daily warm bath or shower is important, rather than a hot bath, which may produce hyperthermia. Nipple exercises and stimulation should not be done, especially in the third trimester, when they can cause uterine contractions and premature labor. Lanolin ointment may damage the areola and nipple. It has not been shown to be effective in preventing sore and cracked nipples. Lanolin is also a common allergen and may contain insecticide residuals such as DDT.

The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?

rubella Most vaccines are contraindicated during pregnancy and are considered teratogenic, such as rubella. Penicillin and acetaminophen may be taken under provider supervision. Folic acid supplementation should be encouraged.

A client in her third trimester of pregnancy wishes to formula feed her baby. What instruction should the nurse provide?

serve the formula at room temperature The nurse should instruct the client to serve the formula to her infant at room temperature. The nurse should instruct the client to follow the directions on the package when mixing the powder because different formulas may have different instructions. The infant should be fed every 3 to 4 hours, not every 8 hours. The nurse should specifically instruct the client to avoid refrigerating the formula for subsequent feedings. Any leftover formula should be discarded.

Untreated hyperemesis can lead to preterm birth. What is the cause of the preterm birth?

severe dehydration resulting in hypoperfusion to the placenta With severe dehydration there is hypoperfusion to the placenta, and preterm labor may be initiated. Ketonuria impacts the fetus' neurologic development but does not initiate preterm labor. Medications used to control nausea and vomiting do not induce labor.

A woman has heard that hypotension can be a problem during pregnancy, but she is not sure what it is or what causes it. The nurse explains that it is simply a temporary bout of low blood pressure due to impaired blood return to the heart. It is commonly caused by sleeping in a position that causes compression of the vena cava blood vessel. To avoid this condition, which suggestion should the nurse make?

sleep on your side Supine hypotension is a symptom that occurs when a woman lies on her back and the uterus presses on the vena cava, impairing blood return to her heart. A woman experiences an irregular heart rate and a feeling of apprehension. To relieve the problem is simple: if a woman turns or is turned onto her side, pressure is removed from the vena cava, blood flow is restored, and the symptoms quickly fade. To prevent the syndrome, advise pregnant women to always rest or sleep on their side, not their back. Sleeping face down is not advised, and sleeping with the feet elevated would not prevent compression of the vena cava.

The nurse is reviewing all of the documentation on determining estimated date of delivery. Which objective data is included? Select all that apply.

sonogram fundal height calculating Naegele rule The following provide objective data on the estimated date of delivery (EDD). The sonogram (a gold standard) provides detailed fetal measurements confirming the gestational age. The fundal height provides growth data, and Naegele rule calculates the estimated date of delivery using the first day of the last menstrual period. A CT scan is not ordered. Pelvic exam findings provide data that the client is pregnant and can also provide data that true labor has begun.

A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?

stop and walk every 2 hours Walking increases venous return and reduces the possibility of thrombophlebitis, a risk for pregnant women who sit for extended periods of time. Limiting mileage, sitting in the back with the feet elevated, and limiting trips may help, but they are not enough to prevent phlebitis.

A pregnant client is concerned about gaining weight. The nurse explains that the extra calories are needed for which purpose? Select all that apply.

supplying energy to the fetus sustaining the elevated metabolic rate providing energy for increased workload promoting cellular growth Increased maternal caloric intake is needed to provide energy and cellular growth in the fetus as well as to provide for the increased workload and metabolic rate of the maternal body. Increased caloric intake does not build strength for the birth process.

The health care provider has prescribed an over-the-counter antacid for a pregnant client in her first trimester who is having ongoing nausea, vomiting, and heartburn. Which instruction concerning the antacid should the nurse prioritize after noting the client is also prescribed a multivitamin supplement?

take antacid 1 hour after the multivitamin Antacids interfere with the uptake of the vitamin contents so the client should take the antacid 1 hour after taking the multivitamin. Caffeine should be avoided due to increases in blood pressure and diuretic effects. Antacids can be taken more often than solely at bedtime, and some clients need them after each meal. Antacids do not have to be taken with dairy products. The priority is to avoid allowing the antacid to cancel out the multivitamin.

During the initial assessment of a 22-year-old pregnant client, the nurse learns that the client usually smokes 2 packs of cigarettes per day. The nurse is planning an education session about lifestyle changes during pregnancy. Which goal would be the most realistic and individualized for this client during this initial clinic visit?

the client reduces her smoking by 50% by the next clinic visit When establishing goals and outcomes, the nurse should be certain that plans are individualized and realistic for a woman's situation and lifestyle and should try to turn long-term goals into more manageable, short-term ones. For example, a goal of reducing smoking during pregnancy may be more realistic than a goal of stopping smoking forever. This eliminates the pressure of making a major permanent lifestyle change. Sudden cessation of smoking is not beneficial because the woman will have to cope with withdrawal symptoms. The client will likely be noncompliant with this request. Having the client research smoking during pregnancy is also unrealistic during this initial visit. The client has to be motivated before the goal can be set.

The nurse is assisting a pregnant client who underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?

the fetal heart rate increases with activity and indicates fetal well-being A nonstress test is a noninvasive way to monitor fetal well-being. A reactive NST is a positive sign the fetus is tolerating pregnancy well by demonstrating heart rate increase with activity, and this indicates fetal well-being. This test is not used to determine congenital anomalies or deformities. It does not determine the speed by which fetus is developing. Further evaluation would be necessary if the results were nonreactive.

The nurse is assisting a primigravida on calculating the due date of her baby using Naegele rule. The most important information provided by the mother is:

the first day of the last menstrual period Naegele rule is calculated using the first day of the last menstrual period. From there, 7 days are added and then 3 months are subtracted. The ovulation date, intercourse date, or last day of the menstrual period are not needed.

A nurse in an obstetric clinic is preparing the staff for a prenatal appointment with an incarcerated pregnant woman. What does the nurse explain is the main difference when an incarcerated client comes to the clinic?

there will be correction officers with her throughout her appointment Care considerations and provision of care are the same as for the nonincarcerated population. During a visit with an off-site provider, the corrections officer may be asked to leave the room during the course of the visit to maintain client privacy. The presence of the officer may be required, however, in situations in which the lack of presence may pose a danger to the healthcare staff or the examination space available offers a flight risk. In some cases the officer may be required to maintain direct visual contact of the inmate at all times. Correctional facility medical staff, including nurses and other healthcare providers, often do not provide any prenatal care or provide only limited prenatal care, with ultrasounds and management of high-risk pregnancies occurring off-site. Typically the woman will not be handcuffed or shackled unless she is a danger to others.

A pregnant woman states that she would like to take a tub bath but has heard from her aunt that this could be dangerous to the baby. Which instruction should the nurse give to the client?

tub baths are fine unless you are unstable on your feet or a re experiencing vaginal bleeding Daily tub baths or showers are recommended. Women should not soak for long periods in extremely hot water or hot tubs, however, as heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. As pregnancy advances, a woman may have difficulty maintaining her balance when getting in and out of a bathtub. If so, she should change to showering or sponge bathing for her own safety. If membranes rupture or vaginal bleeding is present, tub baths become contraindicated because there might be a danger of contamination of uterine contents. Soap is not a teratogen to the fetus.

The nursing instructor is explaining the nursing care that is given to a client during her pregnancy. The instructor determines the session is successful when the students correctly choose which method will be used to evaluate the effectiveness of the nursing care they will provide?

verify that desired outcomes for identified goals have been met Evaluating the effectiveness of nursing care given during pregnancy is to look at the nursing diagnosis for the specific client, identify the goals and their desired outcomes for each diagnosis, and see if the desired outcomes are achieved. This may involve using a preprinted survey and interviewing the client. The nursing diagnoses should be established at the beginning to help guide the care for each individual client.

The nursing instructor is explaining the nursing care that is given to a client during her pregnancy. The instructor determines the session is successful when the students correctly choose which method will be used to evaluate the effectiveness of the nursing care they will provide?

verify that desired outcomes of identified goals have been met Evaluating the effectiveness of nursing care given during pregnancy is to look at the nursing diagnosis for the specific client, identify the goals and their desired outcomes for each diagnosis, and see if the desired outcomes are achieved. This may involve using a preprinted survey and interviewing the client. The nursing diagnoses should be established at the beginning to help guide the care for each individual client.

The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting?

watch it an report if heavy increase in bleeding During the third trimester, if the provider completes a vaginal exam it can be normal to have a small amount of spotting. If the bleeding becomes active or increases, the client needs to be seen immediately. Chadwick sign is a change of color in the vaginal area. The loss of the mucus plug would lead to a much greater amount of blood.