ina 1 quiz 2
A pregnant adolescent at 10 weeks gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, french fries and potato chips. Whybdoes the nurse consider this diet inadequate?
Nutritional composition of the diet places her at risk for low birthweight infant
A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed and irritable. The client states that she is going to . What phase of the first stage of labor does the nurse suspect the client has entered?
Transition
A cx who is pregnant for the first time attends the prenatal clinic. "I'm worried about gaining too much weight because I have heard that it is bad for me." How should nurse respond?
A 25 pound weight gain is rec, but pattern of wt gain is more important than total amount
How should nurse direct care for a client in the transition phase of the first stage of labor?
Help the client to maintain control
a client is scheduled for a non stress test in the 37th week of gestation. A nurse explains the procedure. Which statement demonstrates that the client understands the teaching?
If the heart reacts well, my baby should do okay when I give birth.
A nurse has just finished reviewing how anesthesia will be used during a vaginal birth for a client with class I heart disease. What type of anesthesia does the client discuss that indicates teaching was effective?
Epidural regional
Why should a nurse teach pregnant women the importance of conserving the spurt of energy before labor?
Fatigue may influence the need for pain medication
A client is concerned about gaining weight during pregnancy. What should the nurse explain is the cause of the largest amount of weight gain during pregnancy?
Fetal growth
A nurse is caring for a client who is having a prolonged labor. The client is annoyed and very concerned because her labor is deviating from what she percieves as normal. After the nurse has acknowledged the clients feelings, what is the next best intervention?
I'll rub your back, and you tell me if it helps.
A primigravida tells the nurse that she has morning sickness. What suggestion should the nurse make to help relieve the nausea?
avoid long periods without food
which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?
blowing
A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?
cervix is dilated (False labor does not produce cervical dilation, true labor does)
A client and her partner are working together during the womans labor. clients cervix is now dilated, 7cm and presenting part is low in the midpelvis. What should the nurse instruct the partner to do that would alleviate the clients discomfort during contractions?
deep-breathe slowly.
Why is it important for a nurse in the prenatal clinic to provide nutritional cousneling to all newly pregnant women?
diff cultural groups favor different essential nutrients
A client in the 18th week of pregnancy is scheduled for ultrasonography. What instruction should the nurse give the client?
dont urinate for (at least) 3 hours before the test
What should a nurse suggest to a pregnant client that might help overcome first trimester morning sickness?
eat protein before bedtime
A nurse is caring for an obese client in early labor. Reccomended anesthesia?
epidural anesthesia
a nurse caring for pregnant woman determines she is enaging in the practice of pica. Why prepare a teaching plan for this client?
inedible items are being ingested
A nurse is teaching a primigravida about how she can identify onset of labor. What clinical indicator of labor would necessitate the client to call her health care provider?
membranes rupture or contractions are 5 to 8 minutes apart
A 42-year-old client has an amniocentesis during the 16th week of gestation because of concern about down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?
neural tube defect
A nurse is caring for a patient in labor. what client response indicates that the transition phase of labor probably has begun?
perspires and has a flushed face
Fetus of client in labor is assess to be at -1 station. Where did the nurse locate the fetus' head?
slightly above ischial spines
what position should a nurse teach a client to avoid when the client is experiencing back pain during labor?
supine
A nurse assesses the frequency of a clients contractions by timing them from the beginning of a contraction until when?
to the beginning of the next contraction
When discussing dietary needs during pregnancy, a client tells the nurse "I dont like milk, makes me constipated." What should nurse reccomend?
treat constipation in some other way than omitting milk
during labor, cx recieving epidural anesthesia, sudden episode of severe nausea, skin becomes pale and clammy. Immediate reaction?
turn client on her side
A client arrives in birthing room with the fetal caput emerging. What should the nurse tell the client to do during contraction?
use panting breathing pattern
A pregnant client with iroen deficiency anemia is prescribed iron supplements daily. To increase iron absorption, the nurae should suggest that the client eat foods high in __?
vitamin c (absorption of iron)
At a prenatal visit a client who is at 36 weeks gestation states that she is having uncomfortable ireegular contractions. What should the nurse reccomend?
walk around until they subside
during her first visit to the prenatal clinic it is determined that a client is obese. during the ensuing 5 months, the client has not been successful in adhereing to her nutrititional plan. What finding indicates to the nurse that she has heen successful during the sixth month?
weight gain of 2 pounds
A client in active labor is admitted to the birthing room. A vaginal examination reveals the cervix to be 7cm dilated. On the basis of this finding, what does the nurse expect the client to exhibit?
Strong contractions with intervals of several minutes
What should a nurse include in nutritional planning for a newly pregnant woman of avg ht weighing 145 pounds?
an increase of 300 calories per day
A primigravida in her 10th week of gestation is concerned because she has read that nutrition during pregnancy is important for the growth and development of the fetus. She wants to know something about the food she should eat. What should be the nurses initial response?
ask her what she has been eaten over the last 3 days
A nurse applies an ice pack
local anesthesia
in childbirth classes, nurse is teaching paced breathing techniques to use durinf labor. In which order should the breathing techniques be used as labor progresses?
1- Cleansing breaths 2- Slow, deep breaths 3- Modified-paced breathing 4- Pant-blow breathing 5- Slow, exhalation pushing
Nurse is caring for an adolescent in labor an hour after admitted to birthing unit. Adolescent is anxious and tense. Cries during contractions, requests anesthesia. What interventions are essential before administering epidural anesthesia?
1- Perform baseline asssessmenr exam 2- tell px what to expect with each procedure 3- identify risk factors that contraindicate epidural anesthesia
A cx at 9 weeks gestation asks the nurse on the prenatal clinic if she can have her chorionic villi sampling (CVS) done at this visit. At what week gestation should the nurse respond is the best time for this test?
10 weeks and less than 12 weeks
A woman in labor hears the health care provider tell the nurse that the fetal lie is longitudinal. the mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond?
A vaginal is possible
A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to painful nerve pathway. When operating the TENS unit, which nursing action is appropriate?
Adjust the dial on the unit until the client states the pain is relieved.
a laboring client reports low back pain. What should a nurse rec to the cx coach that will promote comfort?
Apply pressure to her back during contractions
during a clients first visit to the prenatal clinic, a nurse discusses a pregnancy diet. the client states that her mother told her she should restrict her salt intake. What is the nurses best response?
Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet
How does the nurse identify true labor as opposed to false labor?
Cervical dilation is progressive
during a prenatal interview at 20 weeks gestation, the nurse determines that the client has a history of pica. What is the most appropriate nursing action?
Ensure that the clients diet is nutritionally adequate.
A nurse is caring for a primigravida during labor. What does the nurse observe that indicates birth is about to take place?
Perineum begins to bulge with each contraction.
What does a nurse consider the most significant influence on many clients perception of pain when interpreting findings from a pain assessment?
Previous experience and cultural values
A client is admitted to the birthing unit in active labor. what should the nurse expect after an amniotomy is performed?
Progressive dilation and effacement.
A primigravida who is at 40 weeks gestation arrives at the birthing center witj abdominal cramping and a bloody show. Her membranes ruptured 30minutes before arrival. A vaginal examination reveals 1cm dilation and the presenting part at -1 station. After obtaining the fetal heart rate (FHR) and maternal vital signs, what should the nurse do next?
Provide the client with comfort measures used for women in labor.
A nurse is providing dietary counseling to a client who is at 14 weeks gestation. The client is a recent immigrant from Asia and the nurse explores the food the client usually eats. Which food does the nurse counsel her to avoid during pregnancy?
Raw Shellfish, (may be contaminated with hepatites or typhoid) Herbal Supplements (medicinal in nature, do not take without consultinf health care provider) Soft-scrambled eggs (may be contaminated with salmonella)
A client is in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions and is quite irritable. She frequently states "I cannot stand this a minute longer." What does this behavior indicate to the nurse caring for her?
She is entering the transition phase of labor.