Exam 6 Mom Baby

The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for abruptio placentae. Which assessment finding should the nurse prioritize? Sharp fundal pain and discomfort between contractions Painless vaginal bleeding and a fall in blood pressure Pain in a lower quadrant and increased pulse rate An increased blood pressure and oliguria

Sharp fundal pain and discomfort between contractions

A woman with a positive history of genital herpes is in active labor. Assessment reveals vesicles in the perineum area, membranes are ruptured, dilated 5 cm, and effaced 70%. The nurse should prepare the client for which type of birth? Spontaneous vaginal Vacuum-assisted Cesarean Forceps-assisted

Cesarean

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 16, BP 148/110 mm Hg. What other physical assessment by the nurse should be implemented to assess for potential toxicity? Lung sounds Oxygen saturation Deep tendon reflexes (DTRs) Magnesium sulfate level

Deep tendon reflexes (DTRs)

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? Healthy pregnancy Ectopic pregnancy Molar pregnancy Placenta previa

Ectopic pregnancy

A pregnant woman at 38 weeks' gestation is receiving care for preeclampsia and suddenly complains of sharp abdominal pain. Which action should the nurse perform first if the nurse notes a firm, distended and painful abdomen and dark red vaginal bleeding? Implement a tocometer Obtain a full set of vital signs. Place on the fetal heart monitor. Dipstick the urine for protein

Obtain a full set of vital signs.

A 17-year-old primigravida at 37 weeks' gestation has been unable to maintain adequate control of her blood glucose throughout her pregnancy. The nurse should prioritize which action after the health care provider suspects the infant has macrosomia based on the recent ultrasound? Schedule induction of labor today. Allow her to continue without plans for delivery. Schedule cesarean delivery at 39 weeks. Prepare for assessment of fetal lung maturity.

Prepare for assessment of fetal lung maturity.

A pregnant patient 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: limit weight gain to 15 pounds during the pregnancy. check her blood sugars frequently and adjust insulin accordingly. exercise for 1 to 2 hours each day to keep the blood glucose down. begin oral hyperglycemic medications along with the insulin she is currently taking.

check her blood sugars frequently and adjust insulin accordingly.

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."

A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse? "You should talk to the doctor about that; the medications you're on can damage the fetus." "Do you want to talk to a counselor who can help you weigh the pros and cons of having your own child rather than adopting?" "I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet." "That's great. I've got a 4-year-old and a 2-year-old myself."

"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."

A 43-year-old, physically fit, healthy woman who is newly married tells the nurse that she and her husband would like to have a child. What is an appropriate first response? "You must know that's pretty risky. Have you thought about adopting instead?" "I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself." "You're in great shape now, but are you sure that at your age you'll have enough energy to care for a child?" "If you got pregnant now you'd be at risk for multiple fetal pregnancies, chromosomal abnormalities, spontaneous abortion (miscarriage), and hypertension among other things. Are you ready to take that risk?"

"I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself."

The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement? "If I have changes in my vision, I will lie down and rest." "I will weigh myself every morning after voiding before breakfast." "I will count my baby's movements after each meal." "If I have a severe headache, I'll call the clinic."

"If I have changes in my vision, I will lie down and rest."

The nurse is preparing discharge instructions for a client at 32 weeks' gestation who was admitted for PPROM. What is the best response from the nurse when the client asks when she can have intercourse with her husband again? "Intercourse is not recommended until you reach 37 weeks." "The need to keep the infant safe should be of more concern than when to have sex." "That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." "Intercourse has nothing to do with preterm labor; you can have sex with your husband."

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."

A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide? "Amniotic fluid is normally green." "This is meconium-stained fluid from the baby." "You have an infection and need antibiotics." "Green might be a yeast infection and we need to culture the discharge."

"This is meconium-stained fluid from the baby."

A client at 36 weeks' gestation presents to the OB unit reporting continuous, heavy clear vaginal discharge and pelvic pressure. Assessment reveals no signs of labor and positive Nitrazine test. The nurse prepares for which nursing intervention after admitting the client? Administering erythromycin IV Performing daily pelvic exams Administering IM corticosteroids Administering oxytocin

Administering erythromycin IV

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? Contraction stress test Nonstress test Biophysical profile Amniocentesis

Amniocentesis

A 28-year-old client and her current partner present for the first antenatal OB appointment. The client has no children but does question a possible miscarriage 2 years ago with a different partner; however, she never sought medical attention because she felt fine. Labs reveal both client and current partner are Rh negative. Which action should the nurse prioritize? Perform direct Coombs test Assess client for anti-D antibodies Arrange for an amniocentesis Continue with routine procedures and tasks

Assess client for anti-D antibodies

The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize Administer Rho(D) immunoglobulin to the mother. Administer rubella vaccine to the mother before discharge. Assess the mother for isoimmunization. Assess the Rh of the baby.

Assess the Rh of the baby.

The nurse is admitting a woman at 32 weeks' gestation in preterm labor. The nurse should question the order for magnesium sulfate after noting which assessment finding? Cervical dilation of 5 cm Strong, regular contractions Fetus in a breech presentation A spontaneous abortion in an earlier pregnancy

Cervical dilation of 5 cm

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, hemoglobin 13 g/dL, and hematorcrit 37%. Based on these results which instruction would be most appropriate? Check blood sugar levels as ordered by the HCP. Monitor for signs and symptoms of UTI Include iron-enriched foods in her diet. Take daily iron supplements.

Check blood sugar levels as ordered by the HCP.

A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize? Decrease activity and rest more often. Increase fluids and take more vitamins. Bed rest and bathroom privileges only until birth. Discuss induction of labor with the primary care provider.

Decrease activity and rest more often.

The nurse is preparing a postpartum nursing care plan for a single HIV-positive primigravida client. The nurse should prioritize in the plan how to acquire which resource? Breast pump Diapers Car seat Formula

Formula

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the abdominal right lower quadrant? Bed rest for the next 4 weeks Intravenous administration of a tocolytic Immediate surgery Internal uterine monitoring

Immediate surgery

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? Dried apples Fortified grains Dried beans Orange juice

Orange juice

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN perform? Include a set of piper forceps when the table is prepped. Apply pressure to the woman's lower back with a fisted hand. Assist with Nitrazine and fern tests. Prepare to assist with external version.

Prepare to assist with external version.

A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client? Risk for fetal infection related to early rupture of membranes Hopelessness related to potential loss of pregnancy Anticipatory grieving related to high probability for fetal death from placental dysfunction Powerlessness related to inability to sustain pregnancy

Risk for fetal infection related to early rupture of membranes

A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? Apologize and tell her that the photos will be destroyed immediately. Console her with the fact that she has other children. Tell her that the hospital will keep the photos for her in case she changes her mind. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.

Tell her that the hospital will keep the photos for her in case she changes her mind.

A client suffering a miscarriage at 12 weeks' gestations is very upset that the health care provider has ordered a D&C. How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation? "This is the procedure ordered by the doctor." "You have the option to refuse the surgery." "This procedure is needed to adequately remove all the fetal tissue." "Having the D&C will make it easier to get pregnant next time."

This procedure is needed to adequately remove all the fetal tissue."

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should the nurse anticipate performing after noting the fetal head has retracted into the vagina after emerging? Use McRoberts maneuver. Use Zavanelli maneuver. Apply pressure to the fundus. Attempt to push in one of the fetus's shoulders.

Use McRoberts maneuver.

The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation. Assessment reveals prolapsed fetal cord. Which action should the nurse perform first? Turn client to her left side. Place client in a knee-chest position. Use fingers to press upward on the presenting part. Prep for immediate cesarean delivery.

Use fingers to press upward on the presenting part.

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? Uterine rupture Hypertonic uterus Placenta previa Umbilical cord compression

Uterine rupture