ATI RN Learning System 3.0: Maternal Newborn 1

A nurse is teaching a client who is at 13 weeks of gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching?

"I should go to the hospital if I think I may be in labor." Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.

A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching?

"The fibroid can increase the risk for postpartum hemorrhage." Uterine fibroids can increase the risk for postpartum hemorrhage due to the increase in blood supply to the uterus, which supports the fibroid.

A nurse is teaching a client who is at 12 weeks of gestation and has HIV. Which of the following statements should the nurse include in the teaching?

"You should continue to take zidovudine throughout the pregnancy." The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.

A nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate?

"You should walk for at least 30 minutes every day." The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.

A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching?

"You will need to have a full bladder during the ultrasound." The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?

480 ml urine output in 24 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following lab tests will be used to confirm her pregnancy?

A urine test for the presence of human chorionic gonadotropin Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?

Apply pressure to the client's sacral area during contractions The nurse should provide counter pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain.

A nurse is caring for a client whose last menstrual period (LMP) began July 8. Using Nagele's rule, the nurse should identify the client's estimated date of birth (EDB) as which of the following?

April 15 Using Nagele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days.

A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hr. Which of the following actions should the nurse take?

Auscultate for a fetal heart rate Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Betamethasone The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression.

A nurse is providing teaching to a client who is 8 weeks of gestation about manifestations to report to the provider during pregnancy. Which of the following information should the nurse include in the teaching?

Blurred or double vision A client who is pregnant should report experiencing blurred or double vision as these could be a manifestation of gestation hypertension or pre-eclampsia.

A nurse is caring for a client who is at 35 weeks of gestation and has severe preeclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?

Daily weight Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status.

A nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following finding should the nurse expect?

Dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.

A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of the following findings should the nurse expect?

Dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100 to 110 seconds and that the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take?

Decrease the dose of oxytocin by half The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.

A nurse is teaching a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?

Feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing.

A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which of the following findings should the nurse expect?

Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type O negative. Which of the following actions should the nurse take?

Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take?

Obtain blood samples for baseline laboratory values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?

Palpable fetal movement Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy.

A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?

Perform a vaginal examination When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse take?

Prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is caring for a client who has olgiohydramnios. Which of the following fetal anomalies should the nurse expect?

Renal agenesis Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios.

A nurse is teaching a client who is at 12 weeks of gestation about manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching?

Swelling of the face The nurse should instruct the client to report swelling of the face because this can indicate a hypertensive disorder or preeclampsia.

A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider?

Urinary output 20 ml/hr The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.

A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 minutes. Which of the following actions should the nurse take?

Use vibroacoustic stimulation on the client's abdomen for 3 seconds. The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.

A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect?

Uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.

A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations?

Uteroplacental insufficiency A late deceleration in the FHR is a nonreassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.

A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?

Vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.