Exam 3 OB Nursing-Ch19, 20, 21, 23, 24

After teaching a woman about hyperemesis gravidarum and how it differs from the typical nausea and vomiting of pregnancy, which statement by the woman indicates that the teaching was successful?

"I need to avoid strong odors, perfumes, or flavors." The correct response is C. The woman should avoid noxious stimuli such as strong flavors, odors, or perfumes because they might trigger nausea and vomiting.

A woman is suspected of having abruptio placentae. Which of the following would the nurse expect to assess as a classic symptom?

"Knife-like" abdominal pain Expl: The correct response is B. When the placenta separates from the uterine wall, it causes irritation and bleeding into the muscle fibers, which causes pain. Painless, bright-red bleeding indicates placenta previa symptomatology. Excessive nausea and vomiting would be characteristic of hyperemesis gravidarum. Hypertension and headache would be associated with gestational hypertension.

An obese 39-year-old primigravida of African-American descent who is diagnosed with gestational hypertension. Her history reveals that her sister developed preeclampsia during her pregnancy. When describing her diet to the nurse, this client mentions that she tends to eat a lot of fast food.

1. What risk factors does this client have that increase her risk for gestational hypertension? Gloria is a primigravida with a family history of preeclampsia (her sister). She also is an obese woman who is older than 35 years of age. Her diet of fast foods is most likely inadequate in nutritional content. She is also African American. 2. When assessing this client, what assessment findings would lead the nurse to suspect that this client has developed severe preeclampsia? With severe preeclampsia, blood pressure is higher than 160/110 mm Hg on two occasions at least 6 hours apart, proteinuria is greater than 500 mg in 24 hours, and oliguria (less than 500 mL in 24 hours) is present. Other assessment findings may include pulmonary edema, cerebral or visual disturbances (altered level of consciousness, headache, blurred vision, and scotomata), hyperreflexia, and epigastric or right upper quadrant abdominal pain. Laboratory test findings would include increased hematocrit, creatinine, and uric acid levels, thrombocytopenia, and elevated liver enzymes.

Find a website designed to help parents who have suffered a pregnancy loss secondary to a spontaneous abortion. What is its audience level? Is the information up to date?

Appropriate Internet sites might include Sidelines High Risk Pregnancy Support Office (http://www.sidelines.org) and Resolve through Sharing (http://www.ectopicpregnancy.org).

Which of the following lab values need to be monitored by the nurse when providing care for a large for gestational age infant

Blood Glucose since LGA infants are at risk for hypoglycemia, hypocalcemia, hyperbilirubinemia, and polycythemia. Due to their large size, the glucose level drops after birth and they need to be fed early or receive IV fluids to maintain their blood glucose levels within the normal range. Response "A" is incorrect because a WBC is typically performed to determine the presence of an infection. Response "B" is incorrect because a direct Coombs test measures the presence of antibodies against the infant's red blood cells which is associated with Rh and ABO incompatibility. Response "D" is incorrect because the potassium levels are not affected in an LGA infant.

The most serious complication of hydatidiform mole is the development of ___________________ afterward.

Choriocarcinoma

A woman is being discharged after receiving treatment for a hydatidiform molar pregnancy. The nurse should include which of the following in her discharge teaching?

Do not become pregnant for at least a year; use contraceptives to prevent it Assessment of serum chorionic gonadotropin (hCG) is considered a specific tumor marker for gestational trophoblastic disease that isn't resolved. hCG levels are assayed at frequent intervals for up to a year. Pregnancy would obscure the evidence of choriocarcinoma by the normal secretion of hCG. Response "B" is incorrect because there is not a direct link between a molar pregnancy and hypertension continuing after the uterus is empty. Response "C" is incorrect because RhoGAM is given for Rh incompatibility to prevent sensitivity, not as treatment for a molar pregnancy. Response "D" is incorrect because an amniocentesis is not diagnostic of a molar pregnancy in the future.

An abnormal or difficult labor describes ____________.

Dystocia

A pregnancy in which the blastocyst implants outside the uterus is a/an ___________________ pregnancy.

Ectopic

When providing prenatal education to a pregnant woman with asthma, which of the following would be important for the nurse to do?

Ensure she seeks treatment for any acute exacerbation. A pregnant woman with asthma who is having an acute exacerbation will be poorly oxygenated, and thus perfusion to the placenta is compromised. Immediate treatment is needed for her well-being as well as that of the fetus. Corticosteroids are used as a first-line drug therapy for asthma treatment and management because of their anti-inflammatory properties. Having asthma has no influence on the woman's glucose levels, unless she also has diabetes. Bronchodilators usually are inhaled, not given subcutaneously, so instruction about this route of administration would not be necessary.

In assessing a preterm newborn, which of the following findings would be of greatest concern?

Heart Murmur When a newborn is born too soon, fetal circulation may persist into extrauterine life. The ductus arteriosus and foramen ovale may remain open if pulmonary vascular resistance remains high and oxygen levels remain low. This would be manifested by a heart murmur.

Ask a community health maternity nurse how the signs and symptoms of gestational hypertension (including preeclampsia and eclampsia) are taught, and how effective efforts have been to reduce the incidence in the area.

Hopefully the signs and symptoms would be taught to women during their first trimester, and written material would be handed out too. During each prenatal visit, the information should be reinforced to make sure women understand what they are and what to do about them if they should occur.

Which of the following conditions would most likely cause a pregnant woman with type 1 diabetes the greatest difficulty during her pregnancy?

Hyperemesis gravidarum Extreme nausea and vomiting as part of hyperemesis gravidarum would cause fluid and electrolyte imbalances and would alter blood glucose levels tremendously. With placenta previa, the placenta is dislocated, not malfunctioning; it would not have as much of an impact on the pregnancy as would an imbalance of fluids and electrolytes. Abruptio placentae would place the mother at risk for hemorrhage, but the placenta does not govern the blood glucose levels of the mother. Rh incompatibility affects the fetus, not the mother, by causing hemolysis of the red blood cells in the fetus. This process would not influence the mother's glucose levels.

A common metabolic disorder present in both SGA and LGA newborns after birth is ___________________.

Hypoglycemia

Because subcutaneous and brown fat stores were used for survival in utero, the nurse would assess an SGA newborn for which of the following?

Hypothermia Subcutaneous and brown fat stores may be used by the stressed fetus to survive in utero and thus will not be available to provide extrauterine warmth. Excessive red blood cell breakdown is responsible for hyperbilirubinemia, not the breakdown of brown fat stores. Polycythemia is caused by a buildup of red blood cells in response to a hypoxic state in utero; it is not linked to loss of subcutaneous and brown fat stores. Glycogen stores are used for survival in an environment with depleted glycogen and are unrelated to brown fat stores.

A pregnant woman, approximately 12 weeks' gestation, comes to the emergency department after calling her health care provider's office and reporting moderate vaginal bleeding. Assessment reveals cervical dilation and moderately strong abdominal cramps. She reports that she has passed some tissue with the bleeding. The nurse interprets these findings to suggest which of the following?

Inevitable abortion An inevitable abortion is characterized by vaginal bleeding that is greater than slight, rupture of membranes, cervical dilation, strong abdominal cramping, and possible passage of products of conception. The threatened abortion involves slight vaginal bleeding, no cervical dilation and no change in cervical consistency, mild abdominal cramping, a closed cervical os, and no passage of fetal tissue. An incomplete abortion involves intense abdominal cramping, heavy vaginal bleeding, and cervical dilation. A missed abortion involves the absence of contractions and irregular spotting with possible progression to inevitable abortion.

Outline the fetal and maternal risks associated with a prolonged pregnancy.

Maternal/fetal risks associated with a prolonged pregnancy include maternal exhaustion, psychological depression, macrosomia, dysmaturity syndrome, fetal hypoxia, meconium aspiration syndrome, hypoglycemia, and stillbirth.

When assessing the following women, which would the nurse identify as being at the greatest risk for preterm labor

Mom with Hx of pre-term birth Women with a history of preterm birth are at the highest risk for the same in subsequent pregnancies. Having had twins previously would have no bearing on this singleton pregnancy to influence preterm labor. Location of residence is not a risk for preterm labor. The woman's occupation as a computer programmer would not increase her risk of preterm labor. However, standing for long periods in a work environment might increase her risk.

The nurse is developing a plan of care for a woman experiencing dystocia. Which of the following nursing interventions would be the nurse's high priority?

Monitoring FHR patterns the health status of the fetus is paramount throughout the labor process to identify any deviations in a timely manner for decisive interventions to be initiated. Responses "A," "B," and "D" are all important nursing interventions, but don't become the priority over the fetal health status during the labor.

Which of the following women should receive RhoGAM postpartum

Nonsensitized Rh-negative mother with an Rh-positive newborn.

Maintenance on methadone or buprenorphine is the most common medical treatment for which of the following drug addictions?

Opiates because it works to minimize withdrawal symptoms and blocks the effects of illicit opiate drugs. Maintenance therapy is associated with reduced rates of preterm births, longer gestation, and increased birth weights.

Which of the following concepts would the nurse incorporate into the plan of care when assessing pain in a newborn with special needs?

Pain assessment needs to be comprehensive and frequent. Newborns feel pain and require the same level of pain assessment and pain management as adults. Pain assessment, which is comprehensive, involves observations of changes in vital signs, behavior, facial expression, and body movement. It is considered the "fifth vital sign" and should be checked as frequently as the other four signs. All newborns experience pain, not just those undergoing surgical procedures. Preterm newborns have an increased risk of pain because they are subjected to repeat procedures and exposed to noxious stimuli.

When administering magnesium sulfate to a client with preeclampsia, the nurse explains to her that this drug is given to

Prevent Seizures

The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to:

Provide Pain relief measures As women with hypertonic uterine contractions experience a high level of pain related to the high intensity of contractions. Providing comfort measures along with pharmacologic agents to reduce would be a priority. Response "A" is incorrect since a woman experiencing a high level of pain secondary to contraction intensity would not feel like ambulating during this challenging time period. Response "C" is incorrect because with this type of dystocia, augmentation of labor contractions would not be needed. If Pitocin had been infusing prior to the identification of this dystocia pattern, it would be discontinued to reduce the intensity of the contractions. Response "D" is incorrect since an amniotomy would not be a therapeutic measure for hypertonic contractions. This would be an intervention for hypotonic contractions along with Pitocin augmentation.

The term evidence-based refers to the use of which of the following to validate a nurse's practice interventions?

Research Findings Research is the gold standard to prove or disprove effective practices and treatments in health care. Research results are typically carried out and published in referred journals and reviewed by experts in the field for their reliability and validity. Written guidelines, unit procedure manual, and institutional policies are created by individuals or committees that may or may not have the expertise in that field and have unproven efficiency.

The rationale for using a prostaglandin gel for a client prior to the induction of labor is to:

Soften and efface the cervix Prostaglandins soften and thin out the cervix in preparation for labor induction. Although they do irritate the uterus, they aren't as effective as oxytocin in stimulating contractions. Prostaglandin gel would stimulate cervical nerve receptors rather than numb them. Prostaglandins have no power to prevent cervical lacerations.

The nurse is providing care to several newborns with variations in gestational age and birth weight. When developing the plan of care for these newborns, the nurse focuses on energy conservation to promote growth and development. Which measures would the nurse include in the nursing plans of care? Select all that apply. A Keeping the handling of the newborn to a minimum B Maintaining a neutral thermal environment C Decreasing environmental stimuli D Initiating early oral feedings E Using thermal warmers in all cribs F Promoting kangaroo care by caretakers

The correct responses are A, B, and C. Minimal handling, maintaining a neutral thermal environment, and decreasing environmental stimuli are important measures to conserve energy in newborns with variations in birth weight and gestational age. Feeding and digestion will increase energy demands. Thermal warmers may produce hypothermia and thus increase energy demands. Preventing parents from visiting their newborn is not a plan to reduce energy expenditure and could increase stress for both parents and newborn. Another correct response would be "F" since research findings validate improved skin-to-skin contact via kangaroo care increases neurodevelopment in preterm infants. This intervention should be encouraged by nurses.

Outline a discussion you might have with an HIV-positive pregnant woman who doesn't see the need to take antiretroviral agents to prevent perinatal transmission.

The nurse should present the facts that taking the medications will reduce the risk of transmission of HIV and should discuss how the woman and her newborn will benefit from them. Stressing the importance of lowering her viral load throughout her pregnancy and relating it to her well-being might help. Presenting her with the facts is all that the nurse can do, since the final decision will be the woman's.

RhoGAM is given to Rh-negative women to prevent maternal sensitization. In addition to pregnancy, Rh-negative women would also receive this medication after which of the following?

Therapeutic or spontaneous abortion The correct response is A. Any time there is a pregnancy with the chance of maternal and fetal blood mixing, RhoGAM is needed to prevent sensitization or antibody production. Head injury resulting from a car crash is not a situation in which there would be mixing of fetal or maternal blood. The trauma would cause hemorrhage, but not a sensitization reaction. A blood transfusion after hemorrhage would require typing and cross-matching of the client's blood; thus, she would receive blood with her own Rh factor, not one with Rh-positive blood. Because the artificial insemination procedure was unsuccessful, no pregnancy occurred and RhoGAM would not be necessary.

Which of the following would the nurse include when teaching a pregnant woman about the pathophysiologic mechanisms associated with gestational diabetes?

There is progressive resistance to the effects of insulin. Levels of the hormone hPL (insulin antagonist) progressively rise throughout pregnancy, and additional insulin is needed to overcome its resistance. Having a carbohydrate craving is not associated with gestational diabetes. Hyperinsulinemia in the fetus develops in response to the mother's high blood glucose levels. Glucose levels are diverted across the placenta for fetal use, and thus maternal levels are reduced in the first trimester. This lower glucose level doesn't last throughout the gestation, just the first trimester. For the remaining two trimesters, the maternal glucose levels are high because of the insulin resistance caused by hPL.

Discuss various activities a woman with a multiple gestation could engage in to help pass the time when ordered to be on bed rest at home for 2 months.

Various activities for the woman on prolonged bed rest at home could include watching TV, reading, visiting computer sites with chat rooms, talking on the telephone, playing cards or engaging in crafts, having visitors in frequently, and completing educational courses online. The woman could also use the time to develop lists for managing the house while on bed rest, read or play games with her other children, and expand her knowledge related to the upcoming birth of her babies.

The nurse documents that a newborn is post-term based on the understanding that he was born after:

42 weeks. A postterm infant is one born after the 42nd week of gestation. Birth between 38 and 41 weeks is considered within a normal range for a term newborn. A gestation of 44 weeks would be considered extremely long if the dates were calculated correctly.

In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate?

Encouraging them to participate in the newborn's care The parents need to validate the experience of loss. The best way to do this is to encourage them to participate in their newborn's care so that the grieving process can take place. Avoiding the experience of loss inhibits the grieving process. Avoidance prolongs the experience of loss and does not allow the parents to vent their feelings so that they can progress through their grief. It is not the nurse's responsibility, nor it is healthy for the family, to take over decisions for a family. Family members need to support each other and need to decide what is best for their situation. Leaving the family alone can be viewed as abandonment; privacy is important, but leaving them totally alone is not therapeutic.

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as:

Fetopelvic disproportion is defined as a condition in which the fetus is too large to pass through the maternal pelvis. Cervical insufficiency would lead to an abortion, typically in the second trimester, when the heavy gravid uterus would cause pressure on the weakened cervix. A contracted pelvis might cause passageway problems, but if the fetus was small, no problem might occur. Maternal disproportion doesn't indicate where the

When explaining to a pregnant woman about HIV infection and transmission, which of the following would the nurse include?

HIV is most commonly transmitted via sexual contact. The correct response is B. The highest percentage of HIV transmission results from sexual activity, followed by intravenous drug use. Transmission can occur despite a low viral load in the blood of the infected person. Pregnant women who take antiretroviral therapy during their gestation significantly reduce the chances of transmitting HIV to their newborn. The use of standard precautions will minimize the risk of transmission of HIV to health care workers. A very small percentage of nurses contract HIV through needle sticks if using appropriate precautions.

A 27-year-old G3P2, is admitted to the labor and birth suite because of preterm rupture of membranes at an estimated 35 weeks of gestation. She has received no prenatal care and reports this was an unplanned pregnancy. Linda appears distracted and very thin. She reports that her two previous children have been in foster care since birth because the child welfare authorities "didn't think I was an adequate mother." She denies any recent use of alcohol or drugs, but you smell alcohol on her breath. She has a spontaneous vaginal birth a few hours later, producing a 4-lb baby boy with Apgar scores of 8 at 1 minute and 9 at 5 minutes.

What aspects of this woman''s history may lead the nurse to suspect that this infant may be at risk for fetal alcohol spectrum disorder? • Lack of prenatal care • History of substance abuse (alcohol) during previous pregnancies • Children placed in foster care from birth due to poor mothering ability • Appearance on arrival and evidence of being malnourished • Statement about not having any "recent" use of alcohol • Delivery of newborn weighing 4 lb

A client at 26 weeks of gestation came to the clinic to follow up on her previous 1-hour glucose screening. Her results had come back outside the accepted screening range, and a 3-hour glucose tolerance test (GTT) had been ordered. It resulted in three abnormal values, confirming a diagnosis of gestational diabetes. As the nurse in the prenatal clinic you are seeing her for the first time.

c. How will you evaluate the effectiveness of your interventions? • Schedule more frequent prenatal visits to evaluate her health status. • Evaluate glucose values at each visit to validate that they are in the normal range. • Monitor HbA1C to determine past glucose levels.

A 16-year-old primigravida, presents to the maternity clinic complaining of continual nausea and vomiting for the past 3 days. She states that she is approximately 15 weeks pregnant and has been unable to hold anything down or take any fluids in without throwing up for the past 3 days. She reports she is dizzy and weak. On examination, Suzanne appears pale and anxious. Her mucous membranes are dry, skin turgor is poor, and her lips are dry and cracked.

1. What is your impression of this condition? From her history, it appears she has hyperemesis gravidarum, because she is beyond the morning sickness time frame (6 to 12 weeks) and her symptoms are continual. 2. What risk factors does Suzanne have? Her risk factors include young age and primigravida status. 3. What intervention is appropriate for this woman? • Question Suzanne further concerning previous eating patterns and food intake. • Ask what measures she has used at home to stop the nausea and vomiting. • Consult the health care provider concerning hospitalization of Suzanne for IV therapy to correct hypovolemia and electrolyte imbalances. • If home care is in order, advise her to avoid the intake of greasy or highly seasoned foods and to separate food from fluid intake; instruct her on antiemetic medication ordered and possible side effects; and instruct her to return to the clinic if symptoms do not subside within 48 hours.

The nurse is preparing a teaching session about breast-feeding for a group of pregnant women who have various infections listed below. The nurse would include women with which of the following conditions? Select all that apply. A Hepatitis B B Parvovirus B19 C Herpesvirus type 2 D HIV-positive status E Cytomegalovirus F Varicella-zoster virus

A, B, C, E, and F. Women with all the infections listed except HIV can choose to breast-feed. An HIV-positive woman can pass the virus to her newborn through breast milk and should be discouraged from breast-feeding.

A preterm infant is placed under the radiant heat warmer after birth. The nurse evaluates the temperature frequently to prevent which of the following:

Cold Stress since maintaining a preterm infant's temperature is critical to survival. Radiant heat is necessary to prevent cold stress which increases the infant's metabolic and physiologic demands to the limit. Response "B" is incorrect because usually the infant's respiratory rate will increase in response to increased oxygen demands. Response "C" is incorrect since this would not be associated with the infant's temperature, but rather respiratory distress syndrome. Response "D" is incorrect because thermogenesis produces heat by metabolizing brown fat, which would be limited in the preterm infant, thus they would be more prone to coldness.

The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor?

HSV Herpes exposure during the birth process poses a high risk for mortality to the neonate. If the woman has active herpetic lesions in the genital tract, a surgical birth is planned to avoid this exposure. Hepatitis is a chronic liver disorder, and the fetus if exposed would at most become a carrier; a surgical birth would not be expected for this woman. Toxoplasmosis is passed through the placenta to the fetus prior to birth, so a cesarean birth would not prevent exposure. HPV would be manifested clinically by genital warts on the woman, and a surgical birth would not be anticipated to prevent exposure unless the warts caused an obstruction.

A client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of:

Hypotonic labor typically occurs in the active phase; it involves ineffective contractions to evoke cervical dilation and causes secondary inertia. Hypertonic labor is characterized by painful, high-intensity contractions that usually occur in the latent phase. A precipitous labor occurs within 3 hours and cervical dilation is very fast secondary to effective, high-intensity contractions. Dysfunctional labor describes any pattern that doesn't produce dilation and effacement in a timely manner.

SGA and LGA newborns have an excessive number of red blood cells because of:

Hypoxia The fetus's body, in an attempt to compensate for the low oxygen level, produces more red blood cells to carry the limited amount of oxygen available. Thus, polycythemia will be present at birth in a fetus experiencing hypoxia in utero. Hypoglycemia is typically caused by inadequate stores of glycogen and overuse while living in a hostile environment. Low serum calcium levels are associated with perinatal asphyxia and not an increase in red blood cells. Hypothermia is associated with a decrease in body fat, particularly brown fat stores, and is not linked to increased production of red blood cells.

After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have:

Intense Back Pain Having a fetus in a posterior position would cause intense back pain secondary to the fetal head facing the maternal vertebra and causing pressure. Leg cramps are common during pregnancy and not caused by an occiput posterior position, but rather pressure from the heavy gravid uterus toward term. Fetal position would not contribute to nausea and vomiting. Going through transition in labor might cause nausea and vomiting, not the fetal position. A precipitous birth occurs rapidly and is not associated with intense back pain.

Women who are obese have a greater risk of developing which of the following during pregnancy?

Gestational HTN excessive adipose tissue increases cardiac workload, coupled with increased circulatory demands of obesity increases risk for vasoconstriction leading to hypertension. Response "A" is incorrect since type 1 diabetes is generally genetically determined, not environmentally caused. Response "B" is incorrect because the opposite occurs—the maternal blood pressure rises, not decreases. Response "C" is incorrect because infants of obese tend to be large for their gestational age. Research indicates that obesity prior to pregnancy is the strongest predictor of whether a mother will give birth to a large infant.

You have a close friend who has a problem with alcohol but denies it. She now admits to you that she thinks she is pregnant because she missed her period. What specific information and advice should you give her concerning alcohol use during pregnancy?

This study activity is one that many college students can relate to. Confronting the friend who is in denial is the most effective way to bring the issue up. Back it up with observed behaviors that demonstrate the friend's drug or alcohol dependency. Telling the person that you care about her and her well-being can go a long way toward modifying her behavior.

A 26-year-old multipara, is admitted to the labor and birth suite in active labor. After a few hours, the nurse notices a change in her contraction pattern—poor contraction intensity and no progression of cervical dilatation beyond 5 cm. The client keeps asking about her labor progress and appears anxious about "how long this labor is taking."

a. Based on the nurse''s findings, what might you suspect is going on? Since Marsha is multiparous and is in the active phase of labor without progression and the contraction pattern has become less intense, a hypotonic uterine dysfunction should be suspected. b. How can the nurse address client''s anxiety? Give her, in an easily understood manner, facts about dysfunctional labor. Outline expected treatment and outcome. Encourage questions and expression of feelings. Identify how this dysfunctional labor pattern may alter her labor plan. Reassure Marsha about the status of her fetus. Maintain a positive attitude about her ability to cope with this situation.

A client at 26 weeks of gestation came to the clinic to follow up on her previous 1-hour glucose screening. Her results had come back outside the accepted screening range, and a 3-hour glucose tolerance test (GTT) had been ordered. It resulted in three abnormal values, confirming a diagnosis of gestational diabetes. As the nurse in the prenatal clinic you are seeing her for the first time.

a. What additional information will you need to provide care for her? • Explore her typical daily dietary intake. • Ask her if there is a family history of diabetes mellitus. • Take her vital signs, weight, and fetal heart rate. • Assess her coping abilities and capacity for managing diabetes. • Assess her knowledge of the disease process and lifestyle changes needed. • Ask her about symptoms of fatigue, polyuria, polyphagia, and polydipsia. • Ask about previous pregnancy outcomes and the weight of her infants.

A 14-year-old girl comes to the public health clinic with her mother. The mother tells you that her daughter has been "out messing around and has gotten herself pregnant." The girl is crying quietly in the corner and avoids eye contact with you. The mother reports that her daughter "must be following in my footsteps" because she became pregnant when she was only 15 years old. The client's mother goes back out into the waiting room and leaves the client with you.

a. What is your first approach with the client to gain her trust? Open the conversation by asking questions about school activities and her friends. Remain nonjudgmental and bring the discussion to general questions about her monthly cycles. Finally work toward questions about when she last had her period, and assess how many months pregnant she is. Adolescents usually deny a pregnancy for several months, so she may be well into her second trimester. b. List the client''s educational needs during this pregnancy. • Signs and symptoms of preterm labor • Nutritional needs during pregnancy • Need for prenatal care throughout pregnancy • Importance of early detection of complications • Decision about whether to involve her partner • Reasons for the frequency of prenatal visits and importance of keeping them • Symptoms of sexually transmitted infections • Impact of substance abuse on fetal growth and development • Childbearing and parenting classes • Infant growth and development and newborn care

The woman activates her call light and states, "I feel increased wetness down below."

a. What might be occurring? SROM b. How will the nurse confirm the suspicions? Depending on the agency protocol, the nurse may perform or assist with a sterile speculum examination to observe for evidence of fluid pooling in the posterior vagina, any discharge present, inflammation or lesions, or protrusion of the membranes through the cervix. The nurse should also document the amount, color, and consistency of any fluid found during the examination. c. What interventions are appropriate for this finding? • Obtain a baseline set of vital signs to assess FHR patterns for changes possibly indicating a prolapsed umbilical cord. • Use Nitrazine paper to test for the presence of amniotic fluid: it will turn blue in the presence of amniotic fluid because it is alkaline. • Examine a sample of fluid from the vagina under the microscope for a fern pattern once it dries.

A 27-year-old G3P2, is admitted to the labor and birth suite because of preterm rupture of membranes at an estimated 35 weeks of gestation. She has received no prenatal care and reports this was an unplanned pregnancy. Linda appears distracted and very thin. She reports that her two previous children have been in foster care since birth because the child welfare authorities "didn't think I was an adequate mother." She denies any recent use of alcohol or drugs, but you smell alcohol on her breath. She has a spontaneous vaginal birth a few hours later, producing a 4-lb baby boy with Apgar scores of 8 at 1 minute and 9 at 5 minutes.

b. What additional screening or laboratory tests might validate your suspicion? Screening questionnaires can be used to diagnose problem drinking, along with a drug screen (urine or blood) of both her and the newborn to identify specific substances present. The social service agency can also be called to do a more thorough history on this woman. c. What physical and neurodevelopmental deficits might present later in life if the infant has fetal alcohol spectrum disorder? The infant might have attention-deficit/hyperactivity disorder (ADHD), poor impulse control, learning disabilities, and communication problems, as well as growth restriction/developmental problems. It is important to address this woman's alcohol dependence by offering care options such as addiction treatment, mental health therapy, and support. As a nurse, it is important to be sensitive to the client's cultural, spiritual, religious, and emotional needs during this time. Discussion of effective contraception while she is struggling with her addiction is important to prevent fetal alcohol spectrum disorder.

A client at 26 weeks of gestation came to the clinic to follow up on her previous 1-hour glucose screening. Her results had come back outside the accepted screening range, and a 3-hour glucose tolerance test (GTT) had been ordered. It resulted in three abnormal values, confirming a diagnosis of gestational diabetes. As the nurse in the prenatal clinic you are seeing her for the first time.

b. What education will she need to address this new diagnosis? • Dietary modifications to reduce the amount of simple sugars and carbohydrates • Thorough explanation of potential complications of diabetes in pregnancy: ○ Infection: urinary tract infections and monilial vaginitiso ○ Difficult labor and birth: shoulder dystocia, birth trauma, cesarean sectiono ○ Congenital anomalies: cardiac, CNS, and skeletal anomalieso • Literature describing diet, exercise, and glucose monitoring • Outline of hypoglycemia and hyperglycemia symptoms • Referral to nutritionist for diet planning

A 26-year-old multipara, is admitted to the labor and birth suite in active labor. After a few hours, the nurse notices a change in her contraction pattern—poor contraction intensity and no progression of cervical dilatation beyond 5 cm. The client keeps asking about her labor progress and appears anxious about "how long this labor is taking."

c. What are the appropriate interventions to change this labor pattern? Typically some form of labor augmentation is initiated to produce more effective contractions to facilitate cervical dilatation—rupture of membranes or use of IV oxytocin to stimulate the intensity of contractions. If neither one of these interventions changes the hypotonic pattern, a surgical birth is in order.

A 14-year-old girl comes to the public health clinic with her mother. The mother tells you that her daughter has been "out messing around and has gotten herself pregnant." The girl is crying quietly in the corner and avoids eye contact with you. The mother reports that her daughter "must be following in my footsteps" because she became pregnant when she was only 15 years old. The client's mother goes back out into the waiting room and leaves the client with you.

c. What prevention strategies are needed to prevent a second pregnancy? • Ask about her educational goals and encourage her to complete school; perhaps refer her for vocational counseling. • Identify her personal strengths and reinforce positive self-esteem. • Actively involve her in her care at each visit and praise her for her efforts. • Discuss family planning methods appropriate for her and let her decide. • Enhance a positive perception of her ability to succeed in life.

A 10-lb LGA newborn is brought to the nursery after a difficult vaginal birth. The nursery nurse should focus on detecting birth injuries such as ___________________.

clavicle fractures, facial palsies, and brachial plexus injuries