Exam 2
The nurse explains to a pregnant client that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with which substance? legumes meals high in iron orange juice milk
orange juice Explanation: Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron.
What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension? stressing the positive benefits of a healthy lifestyle stressing the avoidance of dairy products stressing regular walks and exercise stressing the increased use of Vitamin D supplements
stressing the positive benefits of a healthy lifestyle Explanation: The nurse should stress the positive benefits of a healthy lifestyle during the preconception counseling of a client with chronic hypertension. The client need not avoid dairy products or increase intake of vitamin D supplements. It may not be advisable for a client with chronic hypertension to exercise without consultation.
A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor? Faulty implantation Exposure to chemicals or radiation Chromosomal defects in the fetus Advanced maternal age
Chromosomal defects in the fetus Explanation: Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.
A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control? Vitamin supplements Plenty of rest Oral hypoglycemic agents Exercise
Exercise Explanation: The three main facets to glycemic control for the woman with pregestational diabetes are diet, exercise, and insulin. An individual with type 1 diabetes uses insulin and not oral hypoglycemic agents. Vitamin supplements may assist with helping to keep the woman healthy but not necessarily through glycemic control. It will be important for the woman to get enough rest throughout the pregnancy but this will not assist with glycemic control.
The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation? Nausea and vomiting Jugular distention Urinary retention Abdominal cramps
Jugular distention Explanation: A woman who has a cardiac condition is at increased risk in the postpartum period. The most important nursing action is to monitor for signs of cardiac decompensation. The nurse should monitor for and report jugular distention, clubbing, and slow capillary refill time. If an irregular pulse is noted, compare it to the apical pulse. The abdominal cramps may be related to the uterus involution. The nausea and vomiting and urinary retention may be related to the surgical procedure and not necessarily the cardiac issue.
A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal? Decrease protein in urine Decrease blood pressure Prevent maternal seizures Reverse edema
Prevent maternal seizures Explanation: The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.
The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy? Repaired atrial septal defect Pulmonary hypertension Secondary hypertension Loud systolic murmur
Pulmonary hypertension Explanation: Pulmonary hypertension is considered the greatest risk to a pregnancy because of the hypoxia that is associated with the condition. The remaining conditions represent potential cardiac complications that may increase the client's risk in pregnancy; however, these do not present the greatest risk in pregnancy.
A new young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which activity? future pregnancies handling the infant with open sores cesarean birth breastfeeding
breastfeeding Explanation: Breastfeeding is a major contributing factor for mother-to-child transmission of HIV. Cesarean birth before the onset of labor and/or rupture of membranes can greatly reduce the chance of transmitting the infection to the infant. Future pregnancies should be discussed and decided on an individual basis. Proper treatment of any open wounds and education should be provided to the mother to ensure she reduces the chance of transmitting HIV to her infant.
A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to: exercise for 1 to 2 hours each day to keep the blood glucose down. limit weight gain to 15 pounds during the pregnancy. check her blood sugars frequently and adjust insulin accordingly. begin oral hyperglycemic medications along with the insulin she is currently taking.
check her blood sugars frequently and adjust insulin accordingly. Explanation: The goal for a mother who has type I diabetes mellitus is to keep tight control over her blood sugars throughout the pregnancy. Therefore, she needs to test her blood sugar frequently during the day and make adjustments in the insulin doses she is receiving.
A nurse is conducting a class on gestational diabetes for a group of pregnant women who are at risk for the condition. The nurse determines that additional teaching is needed when the class identifies which complication as affecting the neonate? macrosomia hypoglycemia hyperglycemia birth trauma
hyperglycemia Explanation: Gestational diabetes is associated with either neonatal complications such as macrosomia, hypoglycemia, and birth trauma or maternal complications such as preeclampsia and cesarean birth.
A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client? preterm rupture of membranes followed by preterm birth hemorrhaging development of eclampsia development of gestational trophoblastic disease
preterm rupture of membranes followed by preterm birth Explanation: Even with precautions, in most instances of polyhydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.
A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum? assessing for cardiac decompensation inspecting the extremities for edema limiting sodium intake ensuring that the client consumes a high fiber diet
assessing for cardiac decompensation Explanation: The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks' gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.
A nursing instructor is teaching students about preexisting illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement? "A pregnant woman with a chronic illness can put the fetus at risk." "A pregnant woman needs to be careful of and cautious about accidents and illnesses during her pregnancy." "A pregnant woman with a chronic condition can put herself at risk." "A pregnant woman does not have to worry about contracting new illnesses during pregnancy."
"A pregnant woman does not have to worry about contracting new illnesses during pregnancy." Explanation: When a woman enters a pregnancy with a chronic illness, it can put both her and the fetus at risk. She needs to be cautious about developing a new illness during her pregnancy as well as having an accident during the pregnancy.
A pregnant client is diagnosed with syphilis. Which response would demonstrate respect for the client and therapeutic communication? "Why didn't you use protection when having intercourse with your partner?" "I noticed that you seem fidgety. Is there something wrong besides your STI?" "I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." "You should have thought about what diseases you could be exposed to. At least you are HIV negative."
"I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." Explanation: The nurse needs to be supportive, empathic and accepting of the client, asking open-ended questions and acting calm and reassuring to her. By acknowledging her fears for her fetus, the nurse is demonstrating respect for her and conveying confidence that the client is trying to take care of her fetus.
A 14-year-old client and her parents have presented at the obstetrician's office in the second trimester; the teen had been hiding the pregnancy. The nurse is helping them develop a plan of care. What is the best thing the nurse can say to the clearly angry parents? "Your daughter needs to make decisions about this pregnancy for herself." "I know you must be very upset and angry about your daughter's pregnancy, but because she's still an adolescent herself, she'll need your guidance in making nutritional and health choices that will be good for the baby and for herself." "Anger won't help this situation at all. You'll only push your daughter away, and she'll be less likely to make good choices." "I understand your anger, but if you had encouraged your daughter to use condoms she would probably not be in this situation."
"I know you must be very upset and angry about your daughter's pregnancy, but because she's still an adolescent herself, she'll need your guidance in making nutritional and health choices that will be good for the baby and for herself." Explanation: The nurse needs to acknowledge the anger of the parents but remember her role is as the client advocate. The nurse needs to encourage the relationship of support between the parents and the client. The nurse should not attempt to lay down ground rules between the client and her parents, and the nurse should acknowledge the parents' feelings in this situation. It is inappropriate to lecture or place blame on the parents.
A pregnant client with a history of asthma since childhood presents for a prenatal visit. What statement by the client would the nurse prioritize? "I have trouble getting comfortable in bed." "I sometimes get a bit wheezy." "I sometimes get a feeling of euphoria." "Certain substances make me sneeze."
"I sometimes get a bit wheezy." Explanation: Wheezing is a classic symptom of asthma. This statement should alert the nurse to the possibility that the client's asthma is not being well-controlled and needs further evaluation and possible intervention. The other statements do not relate to the typical presentation of this disease in pregnancy.
The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or during the birth for the infant. Which statement by the mother indicates that further teaching is needed by the nurse? "If my blood sugars are elevated, my baby's lungs will mature faster, which is good." "I may need an amniocentesis during the third trimester to see if my baby's lungs are ready to be born." "Beginning at 28 weeks' gestation, I will start counting with my baby's movements every day." "My baby may be very large and I may need a cesarean birth to have him."
"If my blood sugars are elevated, my baby's lungs will mature faster, which is good." Explanation: Elevated blood sugars delay the maturation of fetal lungs, not increase maturation time, resulting in potential respiratory distress in newborns born to mothers with diabetes. Doing fetal movement (kick) counts is standard practice, as is the possibility of an amniocentesis to determine lung maturity during the third trimester. Health care personnel should also prepare the mother for the potential of a cesarean birth if the infant is too large.
A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer? "She already has AIDS. That's what being HIV positive means." "HIV antibodies do not cross the placenta; this means the baby will develop AIDS." "HIV is transmitted at birth; having a cesarean birth prevented transmission." "The antibodies may be those transferred across the placenta; the baby may not develop AIDS."
"The antibodies may be those transferred across the placenta; the baby may not develop AIDS." Explanation: Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.
A nurse is caring for a 45-year-old pregnant client with a cardiac disorder who has been instructed by her primary care provider to follow class I functional activity recommendations. The nurse correctly instructs the client to follow which limitations? "You will need to be on bedrest for the remainder of your pregnancy." "You do not need to limit your physical activity unless you experience any problems such as fatigue, chest pain, or shortness of breath." "It is important for you to rest after any physical activity in order to prevent any cardiac complications." "It will be beneficial if you plan rest periods throughout your day."
"You do not need to limit your physical activity unless you experience any problems such as fatigue, chest pain, or shortness of breath." Explanation: Class I recommendations (no physical activity limitations) are suggested for clients who are asymptomatic and exhibit no objective evidence of cardiac disease. The functional classifications system consists of classes I to IV, based on past and present disability and physical signs resulting from cardiac disease.
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response? "Your primary care provider will order safe doses of your medication." "I'll let your primary care provider know how you feel about it." "They won't cause any major defects." "It's OK to not use them if you would feel more comfortable."
"Your primary care provider will order safe doses of your medication." Explanation: Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.
A pregnant client with type 1 diabetes is in labor. The client's blood glucose levels are being monitored every hour and she has a prescription for an infusion of regular insulin as needed based on the client's blood glucose levels. Her levels are as follows: 1300: 105 mg/dL (5.83 mmol/L) 1400: 100 mg/dL (5.55 mmol/L) 1500: 120 mg/dL (6.66 mmol/L) 1600: 106 mg/dl (5.88 mmol/L) Based on the recorded blood glucose levels, at which time would the nurse likely administer the regular insulin infusion? 1300 1600 1400 1500
1500 Explanation: For the laboring woman with diabetes, intravenous (IV) saline or lactated Ringer's is given, and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are maintained below 110 mg/dL (6.11 mmol/L) throughout labor to reduce the likelihood of neonatal hypoglycemia. If necessary, an infusion of regular insulin may be given to maintain this level. The insulin infusion would be given at 1500, based on the blood glucose level being higher than 110 mg/dL (6.11 mmol/L).
A pregnant woman with diabetes is having her hemoglobin (glycosylated) level evaluated. The nurse determines that the woman's glucose is under control and continues the woman's plan of care based on which result? 7.5% 8.5% 6.5% 8.0%
6.5% Explanation: A hemoglobin (glycosylated) level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. A glycosylated hemoglobin level less than 7% indicates that the plan is working and should be continued.
A pregnant woman with diabetes is having a glycosylated hemoglobin (HgbA1C) level drawn. Which result would require the nurse to revise the client's plan of care? 5.5% 6.0% 8.5% 7%
8.5% Explanation: A glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. Therefore, the nurse would need to revise the plan of care.
A client is 33 weeks' pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled? 85 mg/dl 45 mg/dl 120 mg/dl 136 mg/dl
85 mg/dl Explanation: Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.
At 24 weeks' gestation, a client's 1-hour glucose tolerance test is elevated. The nurse explains that, based on this finding, the client will need to take which action? A 3-hour glucose tolerance test for follow-up Monthly hemoglobin A1C levels to rule out diabetes Daily insulin injections for gestational diabetes Daily fingersticks for a fasting blood glucose level
A 3-hour glucose tolerance test for follow-up Explanation: The 1-hour glucose tolerance test is a screening procedure. If the results are elevated, the client needs a 3-hour glucose tolerance test, which is diagnostic of gestational diabetes. Since this is only a screening test, no treatment for gestational diabetes, such as finger-sticks or insulin, is implemented until the 3-hour glucose tolerance test result determines if the client has gestational diabetes. An HgbA1C level does not rule out diabetes; it monitors average blood glucose level over an extended period of time.
A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave? Remind her to continue taking asthma medications, to monitor peak flow daily, and to monitor the baby's kicks in the second and third trimesters. Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications. Note in the chart that the woman was not counseled about her asthma. Schedule an appointment for her to return to discuss her asthma management.
Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications. Explanation: Management of asthma during pregnancy is very important; the nurse must document that the client has the proper ability to manage her asthma for her health and the health of the fetus. Reminding the client to continue taking her prescribed medication and to monitor her peak flow daily is not enough. It is the nurse's responsibility to know that the client knows how to take her medications. Monitoring the baby's kicks in the second and third trimester is an appropriate action. Scheduling a return appointment to discuss asthma management is not appropriate. She could have an asthma attack between the time the nurse sees her and the time of the return appointment. Noting in the chart that the woman was not counseled does not relieve the nurse of his/her obligation to ensure that the woman knows how to use her inhaler and her peak flow meter.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure? Amniocentesis Contraction test Biophysical profile Nonstress test
Amniocentesis Explanation: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.
The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize? Take daily iron supplements. Check blood sugar levels daily. Include iron-enriched foods in the diet. the signs and symptoms of urinary tract infection
Check blood sugar levels daily. Explanation: An elevated blood glucose is concerning for diabetes. A fasting blood glucose level of greater than 140 mg/dl (7.77 mmol/L) or random level of greater than 200 mg/dl (11.10 mmol/L) is concerning; this must be followed up to ensure the client is not developing gestational diabetes. The hemoglobin and hematocrit are within normal limits for this client. The values should be hemoglobin greater than 11 g/dl (110 g/L) and hematocrit greater than 33% (0.33). Values lower than that are possible indications of anemia and would necessitate further evaluation. An individual with higher than normal blood glucose levels is at risk for developing urinary tract infection. This will usually happen after the glucose levels are elevated. Anemia can be treated by increasing the consumption of iron-enriched foods and taking a daily iron supplement.
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints? Molar pregnancy Placenta previa Ectopic pregnancy Healthy pregnancy
Ectopic pregnancy Explanation: The most commonly reported symptoms of ectopic pregnancy are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered. A healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.
A nurse is caring for a 33-year-old primigravida client who is obese and near the end of their second trimester. The client has a history of prepregnancy obesity, hypertension, and smoking. Complete the following sentence(s) by choosing from the lists of options. The client is at highest risk for developing________. The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include ___________. 1. gestational diabetes ectopic pregnancy gestational trophoblastic disease spontaneous abortion 2. change in lifestyle limit exercise during pregnancy refrain from having intercourse during pregnancy limit smoking
Gestational diabetes/change in lifestyle Explanation: Gestational diabetes occurs in pregnant clients who do not have a history of diabetes. Blood glucose and urine are monitored closely for changes in blood glucose levels and glucose or ketones in the urine. Gestational diabetes usually resolves a few weeks after childbirth. Obesity places the client at high risk for gestational diabetes. Pregnant clients with class III obesity (BMI ≥40.0) are more than five and one-half more times likely to develop gestational diabetes. The nurse should educate the client about positive lifestyle changes such as diet, exercise, and cessation of smoking. The client is too far into pregnancy to have an ectopic pregnancy. Gestational trophoblastic disease would have been detected before the end of the second trimester. Spontaneous abortion usually occurs in the first trimester. The nurse should encourage cessation of smoking, not to limit smoking. The nurse should encourage the client to maintain activity or increase it, depending on current activity level, during pregnancy, which will help with weight and blood pressure. The nurse would not recommend the client limit exercise during pregnancy; this would place the client at risk for conditions associated with limited mobility such as deep vein thrombosis. There is no reason the client should refrain from having intercourse during pregnancy.
The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client? Keep the suction equipment readily available. Provide a well-lit room. Keep head of bed slightly elevated. Place the client in a supine position.
Keep the suction equipment readily available. Explanation: The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.
The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information? Maintain a daily blood glucose log Report any signs of possible urinary tract infection Long-term therapy goals Plan daily menus with dietitian
Maintain a daily blood glucose log Explanation: Control of the blood glucose throughout the pregnancy is the primary goal to help decrease potential complications to both the mother and fetus. The mother should keep a daily log of her blood glucose levels and bring this log to each visit for the nurse to evaluate. The other choices of reporting possible signs of a UTI and working with a dietitian to plan menus would also be important but would be secondary to the blood glucose control. It would be inappropriate to discuss long-term goals at this time. This would be handled at a later time and would depend on the mother's situation.
A nurse caring for a pregnant client suspects substance use during pregnancy. What is the priority nursing intervention for this client? Determine how long the client has been using drugs. Obtain a urine specimen for a drug screening. Provide education material on cessation of substance use. Determine if the client has emotional support.
Obtain a urine specimen for a drug screening. Explanation: Substance use during pregnancy is associated with preterm labor, spontaneous abortion (miscarriage), low birth weight, central nervous system and fetal anomalies, and long-term childhood developmental consequences. It is most important to know what the client is taking in order to provide the best care for the client and newborn.
The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement? Fortified grains Dried apples Orange juice Dried beans
Orange juice Explanation: Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron. Dried fruit (such as apples), fortified grains, and dried beans are additional food choices that are rich in iron and should be included in her daily
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? Obtain a voided urine specimen and determine blood type. Check deep tendon reflexes. Palpate the fundus and check fetal heart rate. Measure fundal height.
Palpate the fundus and check fetal heart rate. Explanation: The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching? Placental abruption requires "watchful waiting" during labor and birth. Placenta previa is an abnormally implanted placenta that is too close to the cervix. Placenta previa causes painful, dark red vaginal bleeding during pregnancy. Placental abruption results in painless, bright red vaginal bleeding during labor.
Placenta previa is an abnormally implanted placenta that is too close to the cervix. Explanation: Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless, bright red bleeding in the third trimester. Placental abruption is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor. Placental abruption can result in concealed or apparent dark red bleeding and is painful. Immediate intervention is required for placental abruption.
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? Preterm labor that was undiagnosed Premature separation of the placenta Placenta previa obstructing the cervix Possible fetal death or injury
Premature separation of the placenta Explanation: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.
The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy? Secondary hypertension Loud systolic murmur Pulmonary hypertension Repaired atrial septal defect
Pulmonary hypertension Explanation: Pulmonary hypertension is considered the greatest risk to a pregnancy because of the hypoxia that is associated with the condition. The remaining conditions represent potential cardiac complications that may increase the client's risk in pregnancy; however, these do not present the greatest risk in pregnancy.
A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching? She is at increased risk for type 1 diabetes mellitus after her baby is born. Her baby is at increased risk for neonatal diabetes mellitus. She is at increased risk for type 2 diabetes mellitus after her baby is born. Her baby is at increased risk for type 1 diabetes mellitus.
She is at increased risk for type 2 diabetes mellitus after her baby is born. Explanation: The woman who develops GDM is at increased risk for developing type 2 diabetes mellitus after pregnancy.
A 15-year-old adolescent arrives at the office with a report of flu symptoms, including nausea and vomiting and recent weight loss. A pregnancy test is done and is positive. The client begins crying and tells the nurse her mother will be furious with her. What can the nurse do to assist this adolescent at this point? Tell the adolescent that this is too big of a problem for her to make decisions about and she needs to listen to her mother. Recommend some adoption agencies for her to talk to in the near future. Contact the mother of the adolescent to be sure the child gets prenatal care. Support her by respecting her right to privacy and confidentiality.
Support her by respecting her right to privacy and confidentiality. Explanation: The nurse needs to be an advocate for the adolescent and respect her privacy and confidentiality. It would be advisable for the nurse to encourage the adolescent to talk to her mother or some other support person for help. The nurse has no right to contact the adolescent's mother or to share any information with her. Also, the nurse should not mention adoption at this point to the adolescent. That would be a topic for later discussion.
A client in their third trimester is being seen in the clinic with new-onset fever, lethargy, and painful urination. Vital signs: temperature, 101.2°F (38.4°C); blood pressure, 110/70 mm Hg; heart rate, 98 beats/min. Drag words from the choices below to fill in each blank in the following sentence. The nurse recognizes that the client is at risk for developing _______________________ as evidenced by _______________________ Conditions placenta previa pyeloonephritis UTI eclampsia Findings HR painful urination lethargy BP
UTI/Painful urination Explanation: The client has some of the signs and symptoms of a urinary tract infection (UTI), such as fever and painful urination. One indicator of a UTI is painful urination, which the client is experiencing. There are no indications that the infection has progressed into pyelonephritis. There is no indication that the client is at risk for placenta previa. Based on the client's blood pressure, the client is not at risk for eclampsia. The client's report of lethargy is most likely due to the fever and being in the third trimester. The client's blood pressure of 110/70 mm Hg is within normal limits. The client's heart rate of 98 beats/min is within normal range.
A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum? limiting sodium intake assessing for cardiac decompensation inspecting the extremities for edema ensuring that the client consumes a high fiber diet
assessing for cardiac decompensation Explanation: The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks' gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.
A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition? cytomegalovirus gonorrhea toxoplasmosis chlamydia
cytomegalovirus Explanation: The nurse would be alert for the development of cytomegalovirus infection. Pregnant women acquire active disease primarily from sexual contact, blood transfusions, kissing, and contact with children in day care centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breastfeeding. Chlamydia, gonorrhea, and toxoplasmosis are not spread through contact with children in day care centers.
A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: placenta accrete. hydatidiform mole. ectopic pregnancy. hydramnios.
hydatidiform mole. Explanation: Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.
Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? methotrexate promethazine ondansetron oxytocin
methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.
A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn? clubbed fingers and toes hypertension microcephaly bicuspid valve stenosis
microcephaly Explanation: Signs that are likely to be present in the 10% of newborns who are symptomatic at birth include microcephaly, seizures, IUGR, hepatosplenomegaly, jaundice, and rash.
A pregnant client has been diagnosed with gestational diabetes. Which are risk factors for developing gestational diabetes? Select all that apply. previous large-for-gestational-age (LGA) infant maternal age less than 18 years hypertension genitourinary tract abnormalities obesity
obesity hypertension previous large-for-gestational-age (LGA) infant Explanation: Obesity, hypertension, and a previous infant weighing more than 9 lb (4 kg) are risk factors for developing gestational diabetes. Maternal age less than 18 years and genitourinary tract abnormalities do not increase the risk of developing gestational diabetes.
A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for? placental abnormalities postterm birth type 1 diabetes mellitus type 2 diabetes mellitus
placental abnormalities Explanation: A woman older than 35 years is more likely to conceive a child with chromosomal abnormalities such as Down syndrome. She is also at higher risk for spontaneous abortion (miscarriage), preeclampsia-eclampsia, gestational diabetes, preterm birth, bleeding and placental abnormalities, and other intrapartum complications.
A nursing instructor identifies which factor as increasing the chances of infection when coupled with prolonged labor? number of previous pregnancies maternal age premature rupture of membranes multiple births
premature rupture of membranes Explanation: The risk for infection increases during prolonged labor particularly in association with premature rupture of membranes. The other options do not increase the risk of infection during labor.
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? promote maternal D antibody formation. prevent maternal D antibody formation. stimulate maternal D immune antigens. prevent fetal Rh blood formation.
prevent maternal D antibody formation. Explanation: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity? magnesium sulfate level lung sounds reflexes oxygen saturation
reflexes Explanation: Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.
A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth? amniocentesis results at 34 weeks' gestation the viral load prophylactic antiretroviral therapy (ART) to the infant at birth the mother's age
the viral load Explanation: A woman who has HIV during pregnancy is at risk for transmitting the infection to the fetus during pregnancy or childbirth and to the newborn while breastfeeding. The type of birth, vaginal or cesarean, depends on several factors, including the woman's viral load, use of ART during pregnancy (not waiting until the birth), length of time membranes have been ruptured, and gestational age (not mother's age). With prenatal ART and prophylactic treatment of the newborn, there is a reduced risk of perinatal HIV transmission. The amniocentesis results would not be a factor in preventing the spread of HIV to the infant and may actually lead to the fetus being infected through the puncture site and bleeding into the amniotic sac.
A woman who has sickle cell anemia asks the nurse if her infant will develop sickle cell disease. The nurse would base the answer on which information? Sickle cell anemia is not inherited; it occurs following a malaria infection. Sickle cell anemia is dominantly inherited. Sickle cell anemia has more than one polygenic inheritance pattern. Sickle cell anemia is recessively inherited.
Sickle cell anemia is recessively inherited. Explanation: Sickle cell anemia is an autosomal recessive disease requiring that the person have two genes for the disease, one from each parent. If one parent has the disease and the other is free of the disease and trait, the chance of the child inheriting the disease is zero. If the woman has the disease and her partner has the trait, there is a 50% chance that the child will be born with the disease. If both parents have the disease, then all of their children also will have the disease.
A pregnant woman in her 39th week of pregnancy presents to the clinic with a vaginal infection. She tests positive for chlamydia. What would this disease make her infant at risk for? chickenpox neonatal laryngeal papillomas blindness deafness
blindness Explanation: A pregnant woman who contracts chlamydia is at increased risk for spontaneous abortion (miscarriage), preterm rupture of membranes, and preterm labor. The postpartum woman is at higher risk for endometritis (Fletcher & Ball, 2006). The fetus can encounter bacteria in the vagina during the birth process. If this happens, the newborn can develop pneumonia or conjunctivitis that can lead to blindness.
A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client? seizures diminished reflexes elevated liver enzymes serum magnesium level of 6.5 mEq/L
diminished reflexes Explanation: Diminished or absent reflexes occur when a client develops magnesium toxicity. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.
A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? grade 4 grade 2 grade 3 grade 1
grade 2 Explanation: The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.
A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy? use of oral contraceptives high number of pregnancies history of endometriosis multiple gestation pregnancy
history of endometriosis Explanation: The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple abortions (elective terminations of pregnancy). Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.
Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a client who presents with preterm premature rupture of membranes (PPROM) has completed how many weeks of gestation? less than 40 weeks less than 38 weeks less than 39 weeks less than 37 weeks
less than 37 weeks Explanation: Preterm premature rupture of membranes (PPROM) is defined as the rupture of the membranes prior to the onset of labor in a client who is less than 37 weeks' gestation. PROM (premature rupture of membranes) refers to a client who is beyond 37 weeks' gestation, has presented with spontaneous rupture of the membranes, and is not in labor.
A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best? "You have experienced an incomplete abortion (miscarriage) and must have the placenta and any other tissues cleaned out." "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." "I know that it is sad but the pregnancy must be terminated to save your life." "The choice is up to you but the health care provider is recommending an induced abortion (medical abortion).
"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." Explanation: The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.
A pregnant woman with diabetes is having a glycosylated hemoglobin (HgbA1C) level drawn. Which result would require the nurse to revise the client's plan of care? 6.0% 5.5% 7% 8.5%
8.5% Explanation: A glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. Therefore, the nurse would need to revise the plan of care.
