Maternal-Neonatal Nursing (Antepartum Period, Intrapartum Period, Postpartum Period, and the Neonate)

A 16-year-old unmarried client visiting the prenatal clinic at 32 weeks' gestation and currently weighing 140 lb (63.5 kg) is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inch (158 cm) tall and weighed 120 lb (54.4 kg) before the pregnancy. Which factor would be most important to assess? a. proteinuria b. small-for-gestational-age fetus c. ABO incompatibility d. fluid intake

a. proteinuria Explanation: Because the client is being closely monitored for early signs of preeclampsia, checking the urine for proteinuria is most important. Proteinuria, even in the absence of an elevated blood pressure, is indicative of preeclampsia.Although adolescent pregnancy is associated with an increase in the number of small-for-gestational-age fetuses, this is not indicative of preeclampsia.ABO incompatibility, occurring when the mother has type O blood and the fetus is type A, B, or AB blood, is not associated with preeclampsia. Fluid intake is an important assessment for any pregnant client. However, it is not a primary indication of preeclampsia. Edema of the hands and face is a more important indicator than fluid intake.

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which statement indicates the client's understanding of the nurse's instructions? a. "I'll decrease my intake of green, leafy vegetables." b. "I'll limit fluid intake to four 8-oz (240 mL) glasses." c. "I'll increase my intake of unrefined grains." d. "I'll take iron supplements regularly."

c. "I'll increase my intake of unrefined grains." Explanation: To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids. The use of iron supplements can cause — rather than relieve — constipation.

A client who is 6 weeks' pregnant comes to the clinic for her first prenatal visit. What is the most immediate need for the nurse to address for this client? a. the schedule of prenatal visits b. fundal height measurement c. enrolling the client in a childbirth class d. scheduling genetic testing for the client

a. the schedule of prenatal visits Explanation: To promote the health of the client and her fetus, the nurse should establish a regular schedule of prenatal visits. Prenatal visits are scheduled every 4 weeks up to 28 weeks, then every 2 weeks until 36 weeks. They are scheduled weekly after 37 weeks. Genetic testing isn't needed or scheduled unless the client reports a family history or some suspicion of genetic disease. These tests would be done during specific weeks of gestation. At 6 weeks' gestation, the uterus is not out of the pelvis, so the fundal height cannot be measured. Childbirth classes are generally offered to women closer to their delivery due date, although women may opt to enroll at any time.

A primigravid client at 24 weeks' gestation has received permission from the primary care provider to make a 6-hour automobile trip to visit her parents. After the nurse teaches the client about precautions to take during the trip, which client statement indicates the need for further instruction? a. "I'll drink plenty of fluids to avoid dehydration." b. "I'll sleep for 1 hour at the halfway point of the trip." c. "I'll take frequent rest breaks every 2 hours." d. "I'll be sure to wear the car seat belt while traveling."

b. "I'll sleep for 1 hour at the halfway point of the trip." Explanation: Taking a 1-hour nap at the halfway point of the trip is not necessary. However, taking frequent rest breaks (e.g., every 2 hours) is advisable.Drinking plenty of fluids is recommended to promote adequate hydration and prevent dehydration.The client should be encouraged to take frequent rest breaks and stretch her muscles by walking approximately every 2 hours to increase circulation to the lower extremities and prevent venous stasis.Wearing the seat belt is a recommended safety measure for all people, including pregnant women.

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? a. "Yes, it produces no adverse effects." b. "No, it can initiate premature uterine contractions." c. "No, it can promote sodium retention." d. "No, it can lead to increased absorption of fat-soluble vitamins."

b. "No, it can initiate premature uterine contractions." Explanation: Castor oil can initiate premature uterine contractions and other adverse effects in pregnant women. Castor oil doesn't promote sodium retention and isn't known to increase absorption of fat-soluble vitamins.

Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? a. It determines fetal lung maturity. b. It is noninvasive using real-time ultrasound. c. It will correlate with the newborn's Apgar score. d. It requires the client to have an empty bladder.

b. It is noninvasive using real-time ultrasound. Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin-sphingomyelin ratio (L/S ratio) is used to determine fetal lung maturity. Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. The use of ultrasound requires the client to have a full bladder.

The primary health care provider prescribes intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which medication would be most important for the nurse to have readily available? a. diazepam b. hydralazine c. calcium gluconate d. phenytoin

c. calcium gluconate Explanation: The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam is used to treat anxiety, and usually it is not given to pregnant women. Hydralazine would be used to treat hypertension, and phenytoin would be used to treat seizures.

A client is having a level 2 ultrasound. A nurse knows that physicians order this procedure a. to satisfy the client's curiosity. b. to assess the correct date of gestation. c. for diagnostic purposes when fetal development is in question. d. to provide images of the fetus for family and friends.

c. for diagnostic purposes when fetal development is in question. Explanation: Level 2 ultrasound is more sophisticated and can visualize fetal structures more clearly than a level 1 ultrasound. It's used for diagnostic purposes when fetal development is in question. Typically, level 1 ultrasound is used to assess gestational age. Diagnostic ultrasounds aren't ordered to satisfy the client's curiosity or to provide images of the fetus for family and friends.

A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that they have been maintaining a low-sodium, 1800-calorie diet. Which instruction should the nurse give the client? a. Avoid folic acid supplements to prevent megaloblastic anemia. b. Severely restrict sodium intake throughout the pregnancy. c. Take iron supplements with milk to enhance absorption. d. Increase caloric intake to 2200 calories daily to promote fetal growth.

d. Increase caloric intake to 2200 calories daily to promote fetal growth. Explanation: The client can continue a low-sodium diet but should increase the caloric intake to 2200 calories daily to provide adequate nutrients to support fetal growth and development. Folic acid supplements, a standard component of care, are used to prevent folic acid deficiency, which is associated with megaloblastic anemia during pregnancy. Severe restriction of sodium intake is not recommended because sodium is necessary to maintain fluid volume. Iron supplements should be taken with acidic foods and fluids (e.g., citrus juices) for maximum absorption. Milk decreases the absorption of iron.

A client at 36 weeks gestation has been admitted to the hospital for gestational hypertension. The client's blood pressure is 188/98 mm Hg, and the client has no proteinuria. What is the prioritynursing action at this time? a. Recheck the client's blood pressure in 15 minutes. b. Perform relaxation techniques with the client and retake her blood pressure. c. Notify the charge nurse immediately. d. Notify the physician immediately.

d. Notify the physician immediately. Explanation: Because of the markedly high blood pressure and the diagnosis, it is imperative that the physician is notified immediately. If it is outside of what is considered the appropriate parameters as decided by the physician, it is crucial that the nurse does not delay in notifying the physician. Therefore, it is inappropriate to wait another 15 minutes to rest and/or to recheck the client's blood pressure because doing so would delay communication and potentially put the client and baby at risk for negative health outcomes, including maternal seizure and fetal hypoxia or even death. In some situations, an emergency cesarean birth may be warranted if maternal and fetal conditions are deemed significantly compromised. It is appropriate to notify the charge nurse; however, the most immediate action should be to notify the physician.

A nurse is caring for a 16-year-old pregnant adolescent. The client is taking an iron supplement. What should this client drink to increase the absorption of iron? a. a glass of milk b. a cup of hot tea c. a liquid antacid d. a glass of orange juice

d. a glass of orange juice Explanation: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.

A client and her partner, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as: a. the inability to conceive after 6 months of unprotected attempts. b. the inability to sustain a pregnancy. c. the inability to conceive after 1 year of unprotected attempts. d. a low sperm count and decreased motility.

Explanation: The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse. The inability to sustain a pregnancy doesn't factor into the definition of infertility. A low sperm count and decreased motility may contribute to infertility, but they don't determine infertility.

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of gestational hypertension. Based on this diagnosis, the nurse expects the assessment to reveal: a. 3+ edema in the lower extremities. b. temperature of 101.4° F (38.6° C). c. urine glucose of +2. d. inability to keep food down.

a. 3+ edema in the lower extremities. Explanation: Classic signs of gestational hypertension include edema (especially of the face) and elevated blood pressure. Fever is a sign of infection. Glycosuria, evidenced by a +2 urine glucose level indicates hyperglycemia. Vomiting may be associated with various disorders.

A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission? a. penicillin G potassium I.V. to the client b. amoxicillin trihydrate P.O. to the client c. ceftriaxone I.M. to the neonate immediately after delivery d. methylprednisolone I.V. to the client

a. penicillin G potassium I.V. to the client Explanation: Administering penicillin G potassium I.V. before delivery will prevent fetal transmission of group B streptococcus infection. Amoxicillin P.O. isn't effective against chorioamnionitis caused by group B streptococcus. Treatment with penicillin G potassium should begin before delivery to prevent fetal transmission. Steroids, such as methylprednisolone, aren't bactericidal.

The nurse is assessing a multigravid client at 12 weeks' gestation who has been admitted to the emergency department with sharp, right-sided abdominal pain and vaginal spotting. Which information should the nurse obtain about the client's history? Select all that apply. - history of sexually transmitted infections - number of sexual partners - last menstrual period - cesarean birth - contraceptive use

- history of sexually transmitted infections - number of sexual partners - last menstrual period - contraceptive use Explanation: The client may be experiencing an ectopic pregnancy. Contributing factors to an ectopic pregnancy include a prior history of sexually transmitted infection that can scar the fallopian tubes. Multiple sex partners increase the risk for sexually transmitted infections. Knowledge of the client's last menstrual period and contraceptive use may support or rule out the possibility of an ectopic pregnancy. The client's history of cesarean births would not contribute information valuable to the client's current situation or a potential diagnosis of ectopic pregnancy.

A client at 30 weeks gestation experiences a rupture of membranes with mild contractions 8 minutes apart. Which nursing interventions are included on the plan of care to improve newborn outcomes? Select all that apply. - Maintain the client on the fetal monitor throughout the labor process. - Administer a dose of betamethasone per healthcare provider's order. - Arrange a neonatologist to be available for the birth. - Ensure the mother remains nothing by mouth (NPO) throughout the labor. - Position the mother in a supine position with the feet elevated. - Begin an oxytocin drip once the mother reaches 3 cm dilated.

- Maintain the client on the fetal monitor throughout the labor process. - Administer a dose of betamethasone per healthcare provider's order. - Arrange a neonatologist to be available for the birth. Explanation: The nurse caring for a client at 30 weeks gestation who has a rupture of membranes realizes that preparation is needed for a premature delivery. To improve newborn outcomes, the nurse must be aware of the status of the fetus via a fetal monitor, administer betamethasone (it is best to have at least two doses 12 hours apart) to increase the surfactant level and fetal lung maturity, and have resuscitation equipment available, if needed. It is best have a neonatologist present as well to assess the neonate and plan medical care. The mother typically is permitted to have ice chips at most in case emergency surgery is needed. The mother is not placed in a supine position as there is the potential of compressing the vena cava causing maternal hypotension and reduced blood flow to the fetus. Oxytocin is naturally produced by the posterior pituitary with Pitocin being the synthetic version. It is used to stimulate contractions. Stimulating contractions is not indicated at this time.

A 19-year-old primigravid client is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which interventions? Select all that apply. - Refer client to a nutritionist for the following day. - Ensure that the client has a prescription for an antiemetic. - Ask the health care provider for an anxiolytic prescription. - Encourage return to normal routine when client feels ready. - Coordinate follow-up appointment with provider in 6 weeks. - Discuss plan of care and discharge instructions with client.

- Refer client to a nutritionist for the following day. - Ensure that the client has a prescription for an antiemetic. - Encourage return to normal routine when client feels ready. - Discuss plan of care and discharge instructions with client. Explanation: The nurse case manager should refer the client to a nutritionist so the client is aware of and can be monitored regarding her food intake to assure transition to a normal pregnancy diet with intake of adequate nutrients to support growth and development of the fetus. A PRN (as needed) prescription for an antiemetic is useful to overcome occasional episodes of nausea and vomiting. Encouraging a return to normal activities when the client feels ready gives the client a goal to look forward to and activity is not contraindicated in hyperemesis when the client feels ready to initiate activity. Discussion of the plan of care and discharge instructions is a standard of care when discharging a client from a health care facility. There is no indication for an anxiolytic, and hyperemesis gravidarum typically is not associated with anxiety. Six weeks is too long to wait for a follow-up appointment post hospitalization.

The nurse is caring for a client who has a history of gastric bypass surgery and is now being seen for her first prenatal visit. Which interventions should be included in the plan of care? Select all that apply. - Take a prenatal vitamin with 400 mcg of folic acid. - Refer the client to a registered dietician. - Draw glucose levels at each prenatal visit. - Counsel her that she will most likely gain all of her weight back. - Check urine at each visit for protein and glucose. - Monitor with nonstress tests beginning at 20 weeks.

- Take a prenatal vitamin with 400 mcg of folic acid. - Refer the client to a registered dietician. - Check urine at each visit for protein and glucose. Explanation: Prenatal care includes a general supplementation of 400 mcg of folic acid, and clients with a history of gastric bypass should be referred to a dietician to determine adequate nutrient intake. All pregnant clients have their urine routinely checked for protein and sugar. There is no indication for checking glucose levels at each prenatal visit in clients who have undergone gastric bypass. Gastric bypass clients are not at risk of gaining all of their weight back. No evidence supports implementing stress tests at 20 weeks.

When teaching an antepartum client about the passage of the fetus through the birth canal during labor, the nurse describes the cardinal mechanisms of labor. Using a teaching pelvis and fetus, the nurse demonstrates which sequence during birth? Place these events in the proper sequence. All options must be used. - flexion - extension - descent - internal rotation - expulsion - external rotation

- descent - flexion - internal rotation - extension - external rotation - expulsion Explanation: As the fetus moves through the bony and narrow birth canal, it goes through position changes to ensure that the smallest diameter of fetal head presents to the smallest diameter of the birth canal. Termed the cardinal mechanisms of labor, these position changes occur in the following sequence: descent, flexion, internal rotation, extension, external rotation, and expulsion.

A client at 36 weeks' gestation tells the nurse, "I've been having a lot of backaches lately." After giving instructions about how to decrease the backaches, the nurse determines that the client needs further instruction when she makes which statement? a. "I should walk with my pelvis tilted backward." b. "I may need to put a board under my mattress." c. "I should squat and not bend to pick up objects." d. "I should wear flat or low-heeled shoes."

a. "I should walk with my pelvis tilted backward." Explanation: The client needs further instructions when she says, "I should walk with my pelvis tilted backward." Walking in this position puts greater strain on the back. The client should walk with her pelvis tilted forward. Pelvic tilt exercises can also help the client with backaches. Putting a board under the mattress makes the mattress firmer and provides more support. Squatting and not bending to pick up objects helps decrease back strain. Squatting involves the use of the large thigh muscles rather than those of the back. Flat or low-heeled shoes provide better balance and greater support and can help decrease backaches.

Which statement by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?" a. "This usually disappears after birth." b. "It is a sign of skin melanoma." c. "The discoloration is due to dilated capillaries." d. "It will fade if you use a prescribed cream."

a. "This usually disappears after birth." Explanation: Discoloration on the face that commonly appears during pregnancy, called melasma or chloasma(mask of pregnancy), usually fades postpartum and is of no clinical significance. The client who is bothered by this may be able to decrease its prominence with ordinary makeup. Chloasma is not a sign of skin melanoma. It is not caused by dilated capillaries. Rather, it results from increased secretion of melanocyte-stimulating hormones caused by estrogen and progesterone secretion. No treatment is necessary for this condition.

A prenatal client tells the nurse that they have been eating ginger cookies to treat nausea and vomiting. Which response by the nurse is best? a. "When consumed as a spice in foods, ginger is generally considered safe in pregnancy." b. "It is safer to use a prescription medication than eating ginger while you are pregnant." c. "Wait at least 2 hours to take your prenatal vitamin after eating ginger cookies." d. "You should immediately stop eating ginger-containing foods."

a. "When consumed as a spice in foods, ginger is generally considered safe in pregnancy." Explanation: The herbal supplement ginger is taken to reduce nausea and vomiting. When consumed as a spice in foods, such as ginger cookies, there is a general consensus that ginger is safe. Prescription medications may be necessary to treat severe nausea and vomiting in pregnancy, but they can carry risks such as sedation. Prenatal vitamins should be taken when clients are experiencing the least amount of nausea rather than waiting for a specific time period after eating food. There is no known pregnancy risk from eating ginger as a spice in foods.

An adolescent primigravid client at 26 weeks' gestation has gained 25 lb (11.34 kg) since becoming pregnant. Which of the following is the recommended amount of weight gain during the third trimester? a. 1 lb (0.45 kg) per week. b. 2 lb (0.91 kg) per week. c. 7 lb (3.18 kg) per month. d. 5 to 6 lb (2.27 to 2.72 kg) for the trimester.

a. 1 lb (0.45 kg) per week. Explanation: The pattern of weight gain is commonly more important than the amount. Clients should be advised to gain a total of 25 to 35 lb (11.34 to 15.88 kg) if they are of average weight when becoming pregnant. The recommended pattern is 1 lb (0.45 kg) per month in the first trimester, then 1 lb (0.45 kg) per week in the second and third trimesters. A sudden increase in weight gain is associated with pregnancy-induced hypertension, whereas a sudden weight loss may indicate an illness.

A client who is 16 weeks pregnant reports many mood swings. Which statement accurately describes estrogen and progesterone levels during this client's stage of pregnancy? a. Both estrogen and progesterone levels are rising. b. The estrogen level is much higher than the progesterone level. c. Both estrogen and progesterone levels are declining. d. The estrogen level is much lower than the progesterone level.

a. Both estrogen and progesterone levels are rising. Explanation: Until the seventh month of pregnancy, estrogen and progesterone are secreted in progressively greater amounts. Between the seventh and ninth months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio contributes to mood swings.

When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take? a. Document the finding, which is normal during pregnancy. b. Consult with a cardiologist. c. Contact the client's primary health care provider. d. Explain that this finding may indicate a cardiac disorder.

a. Document the finding, which is normal during pregnancy. Explanation: During pregnancy, a systolic ejection murmur over the pulmonic area is a common finding. Typically, it results from increases in blood volume and cardiac output, along with changes in heart size and position. Other cardiac rhythm disturbances also may occur during pregnancy and don't require treatment unless the client has concurrent heart disease. The nurse should document the finding and check for the murmur during the next visit. The nurse need not consult a cardiologist or the primary care health provider and shouldn't tell the client that this finding indicates a cardiac disorder.

As part of a preconception visit, a couple ask the nurse about their risk for having a child with a genetic disorder. What information should the nurse tell the clients about the risk of having a child with sickle cell disease? a. If both parents have sickle cell trait, the chance is 25% of having a child with sickle cell anemia. b. If one parent has sickle cell anemia, there is a 50% chance the child will have sickle cell anemia. c. If one parent has sickle cell trait, there is a 25% chance that the child will have sickle cell trait. d. If both parents have sickle cell anemia, there is a 50% chance that the child will have sickle cell trait.

a. If both parents have sickle cell trait, the chance is 25% of having a child with sickle cell anemia. Explanation: Sickle cell disease is recessive genetic disorder. Carriers with only one recessive sickle cell gene have sickle cell trait. If both parents have sickle cell trait there is a one-in-four chance with each pregnancy that the child will have sickle cell anemia. If one parent has sickle cell anemia and the other is not a carrier, the child will have sickle cell trait only. If one parent has sickle cell trait, the chance is 50% that the child will also have sickle cell trait. If both parents have sickle cell anemia, there is a 100% chance that the child will have the same disease.

A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? a. Report a heart rate greater than 120 beats/minute to the health care provider. b. Take terbutaline every 4 hours, during waking hours only. c. Call the health care provider if the fetus moves 10 times in an hour. d. Increase activity daily if not fatigued.

a. Report a heart rate greater than 120 beats/minute to the health care provider. Explanation: Because terbutaline can cause tachycardia, the client should be taught to monitor her radial pulse and call the health care provider for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client does not need to contact the health care provider if such movement occurs. The client experiencing premature labor must maintain bed rest at home.

Which of the following situations does the nurse recognize as having the greatest risk for the fetus? a. a fundal height of 27 cm at 32 weeks gestation b. a fetal heart rate of 170 bpm with fetal movements c. a breech lie d. a gestational age of 37 weeks

a. a fundal height of 27 cm at 32 weeks gestation Explanation: Optimal fetal growth and development during pregnancy are assessed with fundal height measurement. Fundal height, measured in centimeters, should equal gestational weeks throughout the pregnancy (e.g., fundal height of 27 cm should occur at 27 weeks gestation). A fundal height of 27 cm at 32 weeks gestation is a very ominous finding that requires immediate attention and investigation. The fetal heart rate (FHR) range is 110-160 bpm but may fluctuate with fetal movement. It is considered tachycardia and at risk only if a FHR is greater than 160 bpm for at least 10 minutes. A breech lie may result in a cesarean section, which carries increased risk after childbirth. There is a possibility that the fetus will change the lie naturally prior to birth or an external cephalic version may be performed. A gestation of 37 completed weeks is considered term.

A pregnant client is diagnosed with partial placenta previa. The nurse should prepare the client for which intervention? a. activity limited to bed rest b. platelet infusion c. cesarean birth d. labor induction with oxytocin

a. activity limited to bed rest Explanation: Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.Placenta previa involves an abnormal implantation of the placenta. Platelets are not affected. Therefore, a platelet infusion is not necessary.Vaginal birth is the preferred method of birth. An immediate cesarean section is not warranted unless fetal distress occurs or the client begins to hemorrhage.Induction of labor should be initiated with caution and only if birth is indicated because of the risk for possible hemorrhage or fetal distress.

A primigravid client at 35 weeks gestation is scheduled for a biophysical profile. After instructing the client about the test, which client statement indicates effective teaching about what the test measures? a. amniotic fluid volume b. placement of the placenta c. amniotic fluid color d. fetal gestational age

a. amniotic fluid volume Explanation: The biophysical profile typically measures five parameters to assess the fetus: fetal breathing, movement, and tone; amniotic fluid volume; and fetal heart reactivity. The test uses a scale of 0 to 2 for each parameter with a maximum score of 10.

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, a nurse should instruct the client to push the control button at which time? a. at the beginning of each fetal movement b. at the beginning of each contraction c. after every three fetal movements d. at the end of fetal movement

a. at the beginning of each fetal movement Explanation: An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn't allow accurate comparison of fetal movement and FHR changes.

A client with gestational hypertension receives magnesium sulfate 50% 4 g in 250 mL D5W over 20 minutes. What priority assessment should the nurse perform when administering this drug? a. deep tendon reflexes b. temperature c. fetal heart rate d. intake and output

a. deep tendon reflexes Explanation: Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. It is administered by IV; 4 g of a 50% solution in 250 mL D5W can be given as a bolus before the dose is titrated for continuous infusion. Magnesium sulfate is a general inhibitor of neurotransmission. As such, the two largest complications are the loss of deep tendon reflexes and the suppression of breathing. These are the priority assessments. If deep tendon reflexes decrease or the respiratory rate is 12 breaths/min or less, the medication should be discontinued and calcium gluconate administered. Magnesium sulfate is excreted entirely through the kidneys so intake and output should be evaluated hourly. The mother becomes very hot and flushed. This is a normal response. The fetal heart rate should not decrease from the drug.

A nurse is assessing a client who's 29 weeks pregnant. What is the most cost-effective method for assessing fetal well-being? a. maternal fetal activity count b. chorionic villi sampling c. ultrasonography d. nonstress test

a. maternal fetal activity count Explanation: Maternal fetal activity count is the least invasive and demanding method for assessing fetal well-being. To use this method, the client simply counts, records, and reports the number of times the fetus kicks during a designated period each day. Chorionic villi sampling is invasive and expensive and should be reserved for pregnant clients at risk for genetic defects. Ultrasonography and nonstress testing, although noninvasive, are expensive and require the use of medical facilities, which may place extra demands on the client's finances.

A client at 6-weeks' gestation comes to the emergency department, and a transvaginal ultrasound confirms ectopic pregnancy with the tube intact. The client will be treated medically. What medication will the nurse prepare to administer to this client? a. methotrexate b. methylergometrine c. bromocriptine d. dinoprostone

a. methotrexate Explanation: An ectopic pregnancy is any pregnancy in which the fertilized ovum implants outside the uterine cavity. As the embryo enlarges, it creates the potential for organ rupture. With early diagnosis, most women with ectopic pregnancy can be treated with an IM injection of methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo. To be eligible for medical treatment, the client must be hemodynamically stable with no active bleeding, the hCG level must be below 5,000 mU/mL, and the mass must measure less than 4 cm. Prostaglandins, misoprostol, and actinomycin have also been shown to be effective in treating an intact ectopic pregnancy. Methylergometrine and dinoprostone stimulate uterine contractions to terminate a pregnancy. Bromocriptine is used to treat menstrual irregularities.

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond? a. "Why don't we discuss this with you at a later time when you're feeling better." b. "You must wait at least 1 year before becoming pregnant again." c. "Let me check with your physician and get you something that will help you relax." d. "Pregnancy should be avoided until all of your testing is normal."

b. "You must wait at least 1 year before becoming pregnant again." Explanation: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 1 year by an experienced health care provider. Discussing this situation at a later time or checking with the physician to give the client something to relax does nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is a vague response and provides the client with little information.

A nurse is assessing a pregnant client in the second trimester. The nurse weighs the client, then compares the current and previous weights. During the second trimester, how much weight should the client gain per week? a. 0.5 lb (0.23 kg) b. 1 lb (0.45 kg) c. 1.5 lb (0.68 kg) d. 2 lb (0.91 kg)

b. 1 lb (0.45 kg) Explanation: During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A client with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy.

When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, the nurse would expect to include which desired target range for blood glucose levels? a. 40 to 60 mg/dL (2.2 to 3.3 mmol/L) between 14:00 and 16:00 hours b. 60 to 100 mg/dL (3.3 to 5.6 mmol/L) before meals and bedtime snacks c. 110 to 140 mg/dL (6.2 to 7.8 mmol/L) before meals and bedtime snacks d. 140 to 160 mg/dL (7.8 to 8.9 mmol/L) 1 hour after meals

b. 60 to 100 mg/dL (3.3 to 5.6 mmol/L) before meals and bedtime snacks Explanation: The goal is to maintain blood plasma glucose levels at 70 to 100 mg/dL (3.5 to 5.6 mmol/L) before meals and bedtime snacks. Below 60 mg/dL (5.6 mmol/L) indicates hypoglycemia. A range of 110 to 140 mg/dL (6.2 to 7.8 mmol/L) suggests hyperglycemia. The target range 1 hour after meals is 100 to 120 mg/dL (5.6 to 6.7 mmol/L).

When planning a class for primigravid clients about the common physiologic changes of pregnancy, the nurse should include which information in the teaching plan? a. The temperature decreases slightly early in pregnancy. b. Cardiac output increases by 25% to 50% during pregnancy. c. The circulating fibrinogen level decreases as much as 50% during pregnancy. d. The anterior pituitary gland secretes oxytocin late in pregnancy.

b. Cardiac output increases by 25% to 50% during pregnancy. Explanation: During pregnancy, the circulatory system undergoes tremendous changes. Cardiac output increases by 25% to 50%, and circulatory blood volume increases by about 30%. The client may experience transient hypotension and dizziness with sudden position changes. Early in pregnancy, there is a slight increase in the temperature, and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fibrinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Braxton Hicks contractions or early labor symptoms.

A client comes to the office for her first prenatal visit. She reports that January 3 was the first day of her last menstrual period. According to Naegele's rule, what date should the nurse record as the estimated date of delivery (EDD)? a. November 10 b. October 10 c. September 10 d. December 10

b. October 10 Explanation: The nurse can calculate EDD using Naegele's rule (add 7 days to the first day of the last menstrual period, then subtract 3 months, and finally add 1 year). In this example, January 3 + 7 days = January 10. Three months prior to that date is October 10 of the previous year. Adding 1 year, her EDD is October 10 of the current year.

A primigravida at 8 weeks' gestation tells the nurse that they want an amniocentesis because there is a history of hemophilia A in their family. The nurse informs the client that she will need to wait until 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? a. Fetal development needs to be complete before testing. b. The volume of amniotic fluid needed for testing will be available by 15 weeks. c. Cells indicating hemophilia A are not produced until 15 weeks' gestation. d. Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

b. The volume of amniotic fluid needed for testing will be available by 15 weeks. Explanation: The volume of fluid needed for amniocentesis is 15 mL, and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation. Amniocentesis carries a slight risk for infection regardless of when the procedure is performed.

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point? a. halfway between the client's symphysis pubis and umbilicus b. at about the level of the client's umbilicus c. between the client's umbilicus and xiphoid process d. near the client's xiphoid process and compressing the diaphragm

b. at about the level of the client's umbilicus Explanation: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm per week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid process owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.

A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? a. labor techniques b. danger signs during pregnancy c. signs and symptoms of pregnancy d. tests to evaluate for high-risk pregnancy

b. danger signs during pregnancy Explanation: No matter how far the client's pregnancy has progressed by the time of the first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they're expected to occur. For example, the nurse should teach about labor techniques near the end of pregnancy; signs and symptoms of pregnancy shortly before they're anticipated, based on the number of weeks' gestation; and any tests a few weeks before they're scheduled.

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for: a. amniocentesis. b. delivery. c. sonography. d. tocolytic therapy.

b. delivery. Explanation: After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor.

A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which hormone? a. progesterone b. estrogen c. somatotropin d. aldosterone

b. estrogen Explanation: Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotropin production. Hyperemesis is also associated with infectious conditions such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole. Progesterone is a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone.

When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, the nurse would anticipate administering intravenously which therapeutic agent if the client develops disseminated intravascular coagulation (DIC)? a. Ringer's lactate solution b. fresh frozen platelets c. 5% dextrose solution d. warfarin

b. fresh frozen platelets Explanation: Treatment of DIC includes treating the causative factor, replacing maternal coagulation factors, and supporting physiologic functions. Intravenous infusions of whole blood, fresh frozen plasma, or platelets are used to replace depleted maternal coagulation factors. Although Ringer's lactate solution and 5% dextrose solution may be used as intravenous fluid replacement, the client needs blood component therapy. Therefore, normal saline must be used. Intravenous heparin, not warfarin, may be administered to halt the clotting cascade.

A client who's 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. Which pregnancy-related physiologic change places the client at greatest risk for more severe cardiac problems? a. decreased heart rate b. increased plasma volume c. decreased cardiac output d. increased blood pressure

b. increased plasma volume Explanation: Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.

A 30-year-old multigravida client has missed three periods and now visits the prenatal clinic because they assume they are pregnant. The client is experiencing enlargement of the abdomen, a positive pregnancy test, and changes in the pigmentation on the face and abdomen. These assessment findings reflect this client is experiencing a cluster of which signs of pregnancy? a. positive b. probable c. presumptive d. diagnostic

b. probable Explanation: The plan of care should reflect that this client is experiencing probable signs of pregnancy. The client may be pregnant, but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease processes as well as pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound confirmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word "diagnostic" is not used to describe the condition of pregnancy.

A newly pregnant client tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to: a. switch brands. b. take the vitamin on a full stomach. c. take the vitamin with orange juice for better absorption. d. take the vitamin first thing in the morning.

b. take the vitamin on a full stomach. Explanation: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this adverse effect. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.

After teaching a pregnant client about potential complications of amniocentesis that must be reported immediately, the nurse determines that the client understands the instruction when she says that she will report which problem? a. nausea b. vaginal bleeding c. urinary frequency d. irregular, painless uterine tightness

b. vaginal bleeding Explanation: Possible complications associated with amniocentesis include hemorrhage from penetration of the placenta, infection of the amniotic fluid, possible puncture of the fetus, and uterine irritation leading to premature labor. Therefore, after amniocentesis, the client should promptly report any vaginal discharge or bleeding, a decrease in fetal movement, or uterine contractions.Typically, nausea, urinary frequency, and irregular, painless, uterine tightness are not complications of amniocentesis.

A nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching? a. "I'll need to lie perfectly still." b. "You won't need to come in and check on me while I'm wearing this monitor." c. "I can lie in any comfortable position, but I should stay off my back." d. "I know that the external monitor increases my risk of a uterine infection."

c. "I can lie in any comfortable position, but I should stay off my back." Explanation: The client demonstrates understanding of the nurse's teaching when she states that she should stay off her back. A woman with an external monitor should lie in the position that is most comfortable to her, but the supine position should be discouraged. It isn't necessary for the client to lie perfectly still. The client should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.

A nurse in a prenatal clinic is assessing a client who is 28 weeks' pregnant. Which findings lead the nurse to suspect that the client has mild preeclampsia? a. glycosuria and blood pressure of 150/92 mmHg b. reduced urine output, 1+ edema c. 1+ protein, blood pressure 142/92 mmHg d. blood pressure 138/78 mmHg, 1+ edema in feet

c. 1+ protein, blood pressure 142/92 mmHg Explanation: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Mild preeclampsia is defined by a blood pressure greater than 140/90 mmHg, 1+ protein, weight gain, and mild hand edema. Abdominal pain, blurry vision, a blood pressure greater than 160/110 mmHg, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. Hyperglycemia is not associated with preeclampsia.

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? a. encouraging ambulation b. serving a nutritious diet c. promoting adequate hydration d. performing nipple stimulation

c. promoting adequate hydration Explanation: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.

A client, approximately 11 weeks pregnant, and their spouse are seen in the antepartal clinic. The client's spouse tells the nurse that they have also been experiencing nausea and vomiting and fatigue along with the client. The nurse interprets these findings as suggesting that the client's spouse is experiencing which complication? a. ptyalism b. mittelschmerz c. Couvade syndrome d. pica

c. Couvade syndrome Explanation: Couvade syndrome refers to the situation in which the expectant spouse or partner experiences some of the discomforts of pregnancy along with the pregnant client as a means of identifying with the pregnancy. Ptyalism is the term for excessive salivation. Mittelschmerz is the lower abdominal discomfort felt by some clients during ovulation. Pica refers to an oral craving for non-edible substances such as clay or starch that some pregnant clients experience.

A client with preeclampsia is receiving magnesium sulfate via infusion pump at 1 g per hour. The nurse's assessment includes temperature 98.1°F (36.7°C); pulse 78 bpm; respirations 12 breaths/minute; blood pressure 128/82 mm Hg; urinary output 90 mL in last 4 hours via urinary catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 bpm; and cervix 4 cm dilated, 80% effaced, station -1. Which is the most appropriate action for the nurse to take? a. Assess the urinary catheter for kinks in the drainage tubing and obtain a urine sample. b. Document findings and continue to monitor the client's progress in labor. c. Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). d. Increase fluid intake intravenously and measure intake and output.

c. Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). Explanation: The nurse must be alert to signs of magnesium sulfate toxicity that include loss of deep tendon reflexes, which is often the first sign (patellar-tendon response is the most common reflex tested); urinary output decreases (should have at least 30 mL per hour); and respirations decrease (12 breaths/min is low and could be developing respiratory distress). The first action would be to stop the magnesium sulfate infusion and notify the HCP. The urinary catheter tubing may be kinked; however, looking at all findings would indicate to the nurse that the client is experiencing magnesium sulfate toxicity. It is not a priority to obtain a urine sample. Documentation is extremely important to complete; however, the nurse must intervene by stopping the magnesium sulfate and notifying the primary HCP. Increasing fluid intake at this point is not appropriate for a client who has magnesium sulfate toxicity. Intake and output should be ongoing for a client on intravenous fluids and magnesium sulfate and a diagnosis of preeclampsia.

A 30-week pregnant client with premature uterine contractions was successfully treated with IV fluids. She is eager to be discharged. The nurse's discharge examination reveals vaginal blood pooling under the client's buttocks, and the client denies pain. Which is the nurse's priority action? a. Monitor the fetal heart rate and maternal vital signs. b. Notify healthcare provider for STAT betamethasone. c. Stop the discharge process, and notify the healthcare provider. d. Prepare for blood typing and cross-matching.

c. Stop the discharge process, and notify the healthcare provider. Explanation: This client is experiencing signs of a placenta previa as indicated by bright red painless bleeding. The bleeding is significant if there is pooling of blood. The priority is to stop the discharge and notify the healthcare provider. Depending upon the amount of bleeding, a decision will be made to have an immediate cesarean delivery or "wait and see" because the mother is only 30 weeks' gestation. The client should be prepared for surgery. At this time the mother will most likely receive a dosage of betamethasone to help mature the fetal lungs. The fetal heart rate should be monitored for evidence of fetal distress. The maternal vital signs should be monitored for symptoms of shock.

A client has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called: a. a first-degree laceration. b. a second-degree laceration. c. a third-degree laceration. d. a fourth-degree laceration.

c. a third-degree laceration. Explanation: Birth may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body.

A client is Rh(D)-negative and D-negative and hasn't formed Rh antibodies. When should the client receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization? a. at about 28 weeks' gestation only b. within 72 hours after birth only c. at about 28 weeks' gestation and again within 72 hours after birth d. at about 32 weeks' gestation and again within 24 hours after birth

c. at about 28 weeks' gestation and again within 72 hours after birth Explanation: A client who is Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies should receive RHO(D) immune globulin at about 28 weeks' gestation and again within 72 hours after birth. Giving RHO(D) immune globulin only at 28 weeks' gestation wouldn't prevent isoimmunization from occurring after placental separation, when fetal blood enters the maternal circulation. Giving RHO(D) immune globulin only within 72 hours after delivery wouldn't prevent isoimmunization caused by passage of fetal blood into the maternal circulation during gestation. Giving RHO(D) immune globulin at 32 weeks' gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies already have formed by then. Giving Rohm(D) immune globulin within 24 hours after birth would be too soon because maternal sensitization occurs in approximately 72 hours.

A newly diagnosed pregnant client tells the nurse, "If I am going to have all of these discomforts, I am not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which perception? a. fear of pregnancy outcome b. rejection of the pregnancy c. normal ambivalence d. limited self-care abilities

c. normal ambivalence Explanation: Clients normally experience ambivalence when pregnancy is confirmed, even if the pregnancy was planned. Although the client's culture may play a role in openly accepting the pregnancy, most new birth parents who have been ambivalent initially accept the reality by the end of the first trimester. Ambivalence also may be expressed throughout the pregnancy; this is believed to be related to the amount of physical discomfort. The nurse should become concerned and perhaps contact a social worker if the client expresses ambivalence in the third trimester. The client's statement reflects ambivalence, not fear. There is no evidence to suggest or imply that the client is rejecting the fetus. The client's statement reflects ambivalence about the pregnancy and is not in and of itself an indication that the client lacks support resources.

After the nurse explains to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which client statement indicates the need for further instruction? a. "Because I have hydramnios, I may gain weight." b. "Hydramnios has been associated with gastrointestinal disorders in the fetus." c. "I should continue to eat high-fiber foods and avoid constipation." d. "I can continue to work at my job at the automobile factory until labor starts."

d. "I can continue to work at my job at the automobile factory until labor starts." Explanation: The client needs further instructions when she says, "I can continue to work at my job at the automobile factory until labor starts." The goal is to avoid preterm labor. Because the client is experiencing severe hydramnios, she will most likely be maintained on bed rest to increase uteroplacental circulation and reduce pressure on the cervix. Hydramnios has been associated with increased weight gain caused by increased amniotic fluid volume. Hydramnios has been associated with gastrointestinal disorders in the fetus, such as tracheoesophageal fistula with stenosis or intestinal obstruction. The client should continue to eat high-fiber foods and should avoid straining, which could lead to ruptured membranes. Stool softeners may also be prescribed. The client should report any symptoms of fluid rupture or labor.

A nurse determines that a client is in false labor. After obtaining discharge orders, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time? a. "Drink coffee or tea to maintain hydration." b. "Apply cold compresses to relieve discomfort." c. "Maintain a supine position to promote rest." d. "Return to the facility if fever occurs."

d. "Return to the facility if fever occurs." Explanation: The nurse should instruct a client in false labor to return to the health care facility if she develops signs or symptoms of infection, such as a fever; if her membranes rupture; if vaginal bleeding occurs; or if her contractions become more intense. The nurse should suggest warm milk or herbal tea, which promote relaxation and rest, instead of coffee or caffeinated tea. Taking a warm tub bath or shower — not applying cold compresses — helps relieve discomfort. A semi-upright position with pillows placed under the client's knees promotes rest.

A 40-year-old primigravid client with AB-positive blood visits the outpatient clinic for an amniocentesis at 16 weeks' gestation. The nurse determines that the most likely reason for the client's amniocentesis is to determine if the fetus has which problem? a. cri-du-chat syndrome b. ABO incompatibility c. erythroblastosis fetalis d. Down syndrome

d. Down syndrome Explanation: Because of the client's age, the amniocentesis is most likely being done to evaluate for Down syndrome (trisomy 21). Women older than 35 years are at higher risk for having a child with Down syndrome. Cri-du-chat syndrome is a genetic disorder involving a short arm on chromosome 5. This disorder is not associated with mothers who are older than 35 years. The client is AB-positive, so the amniocentesis is not being done for ABO incompatibility, in which the mother is type O and the fetus is type A, B, or AB. The amniocentesis is not being done to detect erythroblastosis fetalis because the mother is Rh-positive.

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which factor? a. a decrease in vaginal glycogen stores b. development of a sexually transmitted infection c. prevention of expulsion of the cervical mucus plug d. control of the growth of pathologic bacteria

d. control of the growth of pathologic bacteria Explanation: An increase in clear, highly acidic vaginal secretions is a normal finding during pregnancy that aids in controlling the growth of pathologic bacteria. Vaginal secretions increase because of the influence of estrogen secretion and increased vaginal and cervical vascularity. The highly acidic nature of the vaginal secretions is caused by the action of Lactobacillus acidophilus, which increases the lactic acid content of the secretions. The increased acidity helps to make the vagina resistant to bacterial growth. During pregnancy, estrogen secretion fosters a glycogen-rich environment. Unfortunately, this glycogen-rich, acidic environment fosters the development of yeast (Candida albicans) infections, manifested by itching, burning, and a cheese-like vaginal discharge. If the client had a sexually transmitted infection, most likely they would have additional symptoms, such as lesions in the genital area or changes in color, consistency, or odor of the vaginal secretions. An increase in vaginal secretions does not help prevent expulsion of the mucus plug. The mucus plug is held in place by the cervix until the cervix becomes ripe.

After determining that a pregnant client is Rh-negative, a physician orders an indirect Coombs' test. The purpose of performing this test with a pregnant client is to: a. determine the fetal blood Rh factor. b. determine the maternal blood Rh factor. c. detect maternal antibodies against fetal Rh-negative factor. d. detect maternal antibodies against fetal Rh-positive factor.

d. detect maternal antibodies against fetal Rh-positive factor. Explanation: The indirect Coombs' test measures the number of antibodies against fetal Rh-positive factor in maternal blood. The maternal blood Rh factor is determined before the indirect Coombs' test is done. No maternal antibodies against fetal Rh-negative factor exist.

After the nurse reviews the primary health care provider's (HCP's) explanation of amniocentesis with a multigravida client, which complication if stated by the client indicates that they need more teaching about the procedure? a. risk for infection b. possible miscarriage c. risk for clubfoot (congenital talipes equinovarus) d. fetal organ malformations

d. fetal organ malformations Explanation: There is little risk for fetal organ malformations from amniocentesis. One of the primary risks of amniocentesis is stimulation of the uterus and possible miscarriage. Other risks include hemorrhage from penetration of the placenta, infection of the amniotic fluid, and puncture of the fetus. Clubfoot has been associated with amniocentesis, especially when it is performed before 15 weeks.

An antenatal primigravid client has just been informed they are carrying twins. The plan of care includes educating the client concerning factors that put the client at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when they indicate carrying twins puts the client at risk for which complication? a. preterm labor b. twin-to-twin transfusion c. anemia d. group B streptococcus

d. group B streptococcus Explanation: Group B streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation. The normal uterus is only able to distend to a certain point, and when that point is reached, labor may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestations. The donor twin may become growth restricted and can have oligohydramnios, while the recipient twin may become polycythemic with polyhydramnios and develop heart failure. Anemia is a common problem with multiple gestation clients. The birth parent is commonly unable to consume enough protein, calcium, and iron to supply their needs and those of the fetuses. A maternal hemoglobin level below 11 mg/dL (110 g/L) is considered anemic.

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, the client has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on their vagina. The nurse refers the client to a primary health care provider (HCP) because the nurse suspects which sexually transmitted infection? a. gonorrhea b. Chlamydia trachomatis infection c. syphilis d. herpes genitalis

d. herpes genitalis Explanation: The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. Women infected with C. trachomatis commonly do not have symptoms, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre.

A multiparous client at 14 weeks' gestation has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for which value? a. white blood cells b. albumin c. glucose d. ketones

d. ketones Explanation: When a client is not able to eat, the intake of carbohydrates is dramatically reduced, causing fat to be burned for energy. Improper fat metabolism results in ketones in the urine from the starvation this client is experiencing.Presence of white blood cells in the urine would suggest a possible urinary tract infection.Albumin in the urine is associated with kidney or heart disease.Glucose in the urine is associated with diabetes mellitus.

While caring for a pregnant adolescent client, a nurse should develop a care plan that incorporates the adolescent's: a. age of menarche. b. family and home life. c. healthy eating habits. d. level of emotional maturity.

d. level of emotional maturity. Explanation: When assessing an adolescent initially, the nurse should try to determine the adolescent's level of emotional maturity. This information is used as the basis for the nursing care plan. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the adolescent.

A nurse is reviewing a pregnant client's nutritional status. To determine whether the client has an adequate intake of vitamin A, the nurse should assess the client's diet for consumption of: a. salmon. b. oatmeal. c. chicken. d. milk.

d. milk. Explanation: Common food sources of vitamin A include dairy products, liver, egg yolks, fruits, and vegetables. Fish and meat are good sources of protein. Cereals, especially whole grains, are good sources of niacin, vitamin B1, and vitamin B6.

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. The client's cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next? a. red blood cell count b. degree of discomfort c. urinary output d. temperature

d. temperature Explanation: Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.

A 36-year-old primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. Why does the nurse need to assess the client's fundal height? a. to determine the level of uterine activity b. to identify the need for increased weight gain c. to assess the fetal position d. to estimate the fetal growth

d. to estimate the fetal growth Explanation: Assessment of fundal height is a gross estimate of fetal growth. By 20 weeks' gestation, the height of the fundus should be at the level of the umbilicus, after which it should increase 1 cm for each week of gestation until approximately 36 weeks' gestation. A fundal height that is significantly different from that implied by the estimated gestational age warrants further evaluation (e.g., ultrasound examination) because it possibly indicates multiple pregnancy or fetal growth retardation. Fundal height estimation will not determine uterine activity or a need for increased weight gain. Leopold maneuvers will determine fetal position, but are not typically done in the second trimester when the fetus is still freely moving.