Jensen's Health Assessment 3rd Ed. | Chapter 25

A woman in her sixth month of pregnancy comes in for her first prenatal examination. She complains today of headache and abdominal pain of several months' duration. She appears somewhat hurried or nervous. What questions would the nurse ask next?

"Do you feel safe at home?"

A client who is 32 weeks gestation tells the nurse that she has been experiencing shortness of breath when walking up the steps at home. She is concerned that something is wrong. What is the nurse's best response?

"The enlarging uterus pushes against your diaphragm and this makes breathing shallow"

A pregnant client states, "I am only 6 weeks pregnant, but the morning sickness is awful. When is it going to stop?" What is the best response by the nurse?

"Usually after 12 weeks, when the placenta starts managing the production of progesterone, morning sickness ends."

The 22-week prenatal client states, "I feel a pulling type of pain around my belly button." Which is the best initial response by the nurse?

"Your body is stretching as the baby grows."

While caring for a pregnant client at 8 weeks' gestation, the client asks the nurse, "When can you hear the baby's heartbeat?" The nurse should instruct the client that when a Doppler device is used, the earliest time when the fetal heart rate can be heard is the gestational age of

10 weeks.

The clinic nurse is assessing a client who is pregnant at 18 weeks' gestation. The nurse is obtaining a fetal heart rate using Doppler ultrasound. What fetal heart rate represents an expected finding?

130 beats per minute

A pregnant woman should drink at least

2 L/day of water

A pregnant client of normal weight is concerned about excessive weight gain during her pregnancy. She states, "I don't want to get fat!" The nurse should inform her that she can expect to gain how much weight during her pregnancy?

25 to 30 pounds

The nurse is measuring the fundal height of a woman who is 28 weeks' gestation. Which measurement would the nurse expect?

28 cm

Which prenatal client has the greatest risk of delivering a baby with a defect?

A 6-week pregnant woman who takes lithium (Eskalith) daily for bipolar disease

A client at 26 weeks' gestation appears at the clinic for her first prenatal visit. During the health interview, she states that she has been a habitual cocaine user. The nurse understands that this client is at risk for what complication?

Abruptio placenta

A woman who recently found out she was pregnant is asking what day her baby is due. The first day of her last menstrual period was July 12, 2014. When is she due according to Naegele's Rule?

April 19, 2015 Rationale: using Nagele's rule, 3 months are subtracted and 7 days are added, plus 1 year from the date of the last menstrual period.

The nurse understands that the maternal uterus should be at what location at 20 weeks' gestation?

At the level of the umbilicus

A nurse at the health care facility assesses a client in the 20th week of gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?

At the level of the umbilicus Rationale: In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 and 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy (such as at 40 weeks' gestation), the fundus should reach the xiphoid process.

A nurse at the health care facility assesses a client in the 40th week of gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?

At the xiphoid process Rationale: In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 and 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy (such as at 40 weeks' gestation), the fundus should reach the xiphoid process.

During a prenatal visit, the nurse inspects the skin of the client's abdomen. What would the nurse identify as an abnormal finding?

Bruising

The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate?

Document and continue to follow at future visits.

The nurse should frequently monitor a client at 8 weeks' gestation who has a history of hydatidiform molar pregnancy (gestational trophoblastic disease) for which problem over the next 3 to 4 weeks?

Elevated blood pressure

The nurse is assessing a pregnant client with Leopold maneuvers. Which finding should the nurse expect when completing this assessment?

Fetal buttocks feel like a soft mass

A pregnant client tests positive for Group B Streptococcus. The nurse understands that what intervention is necessary to protect the infant?

Give the mother antibiotics 4 hours prior to delivery.

A client who is at 23 weeks' gestation tells the nurse, "I just burn up all the time. I can't even sleep with any covers on me!" The nurse explains to the client that this is primarily due to which physiologic change?

Increased basal metabolic rate

During an assessment the nurse notes that a pregnant client has nasal mucosal swelling, redness, and occasional epistaxis. What should the nurse consider is causing these symptoms?

Increased estrogen production

A 28-year-old primigravida client with diabetes mellitus, in her first trimester, comes to the health care clinic for a routine visit. The client reports frequent episodes of sweating, giddiness, and confusion. What should the nurse tell the client about these experiences?

Increased secretion of insulin occurs in the first trimester Rationale: Increased secretion of insulin in the maternal body in the first trimester is due to the rise in serum levels of estrogen, progesterone, and other hormones. During the second half of pregnancy, tissue sensitivity to insulin progressively decreases, producing hyperglycemia and hyperinsulinemia. Use of insulin needs to be increased not reduced as pregnancy advances. Insulin resistance becomes maximal not minimal in the latter half of the pregnancy.

A client comes to the prenatal clinic for a follow-up examination. When assessing the breasts, which of the following would the nurse expect to find? Select all that apply.

Increased sensitivity Nodular breasts Prominent veins

A pregnant client at her first prenatal visit asks the nurse how much weight she should gain during the first part of her pregnancy. What would the nurse answer for the expected weight gain during the first trimester?

Less than 7 lb

A client who is pregnant presents to the health care clinic with reports of left breast pain, redness, and warmth. The nurse recognizes these as signs of which abnormal finding of pregnancy?

Mastitis

Before beginning the initial prenatal examination, a nurse should instruct a client to complete what procedure before undressing?

Obtain a clean catch urine Rationale: The first procedure a nurse should ask the client to do is obtain a clean catch, midstream urine before undressing. Lab tests can be done after the examination is complete. At the first visit, the fetus is too small to be measured or ultrasound done.

A client who is pregnant presents to the health care clinic for a routine checkup. She tells the nurse that her hands have been tingling over the past 2 weeks and they often become numb at night. What assessment should the nurse perform to obtain data in regards to this subjective information?

Perform the Phalen's test

The pregnant client tells the nurse she has a history of mitral valve stenosis as a sequela of rheumatic fever. The nurse plans to closely monitor the client based on the understanding that which physiologic change in pregnancy increases this client's risk for complications?

Physiologic anemia

A client is at 20 weeks' gestation and is scheduled for a fetal survey with ultrasound. What will the ultrasound reveal about the placenta? (Select all that apply.)

Placement of the placenta Functional grade of the placenta Size of the placenta

A pregnant client is sitting with a younger child waiting for a scheduled appointment. What observation about the other child caused the nurse to assess the client about alcohol intake while pregnant? Select all that apply.

Poor coordination Hyperactive behavior Difficulty with attention Abnormal facial features

The nurse is completing the assessment of a client who is 26 weeks' pregnant. Assessment reveals a fundal height of 21 cm. How should the nurse follow up this assessment finding?

Refer the client due to possible intrauterine growth retardation.

A pregnant client visits the clinic for the first time. The nurse should explain to the client that she will have initial routine blood tests, which include testing for

Rh status

A client is 28 weeks pregnant when lab work is completed in the clinic. The client is Rh negative with a white blood cell count of 12,000 and normal platelet count. The nurse should plan for which treatment?

RhoGAM administration. Rationale: Mothers with Rh negative blood are given RhoGAM at approximately 28 weeks' gestation or in cases of abdominal trauma or miscarriage. This is to prevent isoimmunization of the mother, which can endanger future pregnancies. Anemia may be treated with iron supplementation or iron-rich foods. Thalassemias may require referral to specialists because the condition poses some risks to the fetus. Patients with low-platelet levels are at risk for hemorrhage or disseminated intravascular coagulation and may not be candidates for epidurals. White blood cell (WBC) counts are usually elevated in pregnancy; they may be as high as 12,000/mm3 prenatally, and during labor they may rise as high as 30,000/mm3. WBCs in excess of these numbers suggest a potential infection.

A pregnant client in her first trimester states, "I think I must be having a miscarriage. I have sharp pains in my lower abdomen sometimes!" What does the nurse understand is happening to this client?

The client is experiencing stretching of the round and broad ligaments. Rationale: In the first trimester of pregnancy, sharp pains in the lower abdomen are common. Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short and have a stabbing quality. They are not repetitive, but are often associated with position changes, or later fetal movements.

At what point in the pregnancy is it possible for the fetus to survive outside the womb?

The end of the second trimester

A client in her third trimester is scheduled for a nonstress test. What is the purpose of the nonstress test for the client?

To determine the well-being of the fetus

A woman is only 30 weeks pregnant, but the physician determines that the fetus must be delivered for the safety of the mother. The physician orders a glucocorticosteroid injection to be given. Why does the physician order this injection?

To promote the formation of surfactant in the fetal lungs

One cardiac change that commonly occurs in a pregnant client is

an increase in maternal blood volume by 40% to 50%.

A primigravida presents to the clinic with headache and proteinuria. The nurse obtains a blood pressure of 180/110 and suspects the client is suffering from:

preeclampsia Rationale: Clinical manifestations of preeclampsia include significantly increased hypertension, persistent headache, malaise, sudden edema, especially of the face, and proteinuria 1+ or greater. Hypoglycemia is characterized by hunger, shakiness, dizziness, sweating, blurred and/or double vision, and confusion. Clinical manifestations of pyelonephritis may include fever, malaise, flank pain, polyuria, urgency, dysuria, and hematuria. Clinical manifestations of iron deficiency anemia may include pale skin, shortness of breath, extreme fatigue, weakness, dizziness, tachycardia, headache, irritability, and restless legs syndrome.