Test 1 Study Guide

What assessment data of a laboring woman would require further intervention by the nurse?

All data are normal except for the maternal heart rate of 125 beats/minute. Normal maternal heart rate is 60-100 beats/minute. The elevated heart rate is a possible signal of developing complications.

The nurse assesses the perineal changes of a woman in the second stage of labor. The figure below represents which perineal change?

Crowning occurs when the fetal head is visible. Anterior-posterior slit occurs as the perineum flattens and is followed by an oval opening. As labor progresses, the perineum takes on a circular shape, followed by crowning.

After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which statement?

"Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average." The National Academy of Sciences Institute of Medicine and Health Canada recommend that women gain 25 to 35 lb (11.5 to 14.5 kg) during pregnancy. The pattern of weight gain is as important as the total amount of weight gained. Underweight women and women carrying twins should have a greater weight gain. Typically, women should gain 3.5 lb (1.6 kg) during the first trimester and then 1 lb (0.45 kg)/week during the remainder of the pregnancy (24 weeks) for a total of about 27 to 28 lb (12.2 to 12.7 kg). A weight gain of only 6.6 lb (3 kg) in the second and third trimesters is not normal because the client should be gaining about 1 lb (0.45 kg)/week, or 12 lb (5.4 kg) during the second and third trimesters. Gaining 12 lb (5.4 kg) during each trimester would total 36 lb (16.2 kg), which is slightly more than the recommended weight gain. In addition, nausea and vomiting during the first trimester can contribute to a lack of appetite and smaller weight gain during this trimester.

A client asks, "Can my partner and I still engage in sexual intercourse while I'm pregnant?" What should the nurse tell the client?

"Although your sexual desire may change, intercourse is safe during an uncomplicated pregnancy." Generally, engaging in the usual pattern of sexual activity during pregnancy is safe as long as the client is comfortable and no complications arise. The client needs to be informed that some women find intercourse uncomfortable during the first and third trimesters, owing to the common discomforts of pregnancy.Numerous myths about engaging in sexual activity during pregnancy exist. However, coitus does not harm the fetus. Coitus interruptus is not considered the preferred method of sexual activity.Avoiding sexual activity until the 16th week of pregnancy is not necessary because coitus does not harm the fetus.During the third trimester, sexual intercourse is still considered safe. However, because of the increased size of the woman's abdomen, the couple should consider coital positions other than male superior position. Sexual intercourse would be contraindicated only if the woman experiences bleeding or ruptured membranes. Also, after 32 weeks' gestation, women with a history of preterm labor should be advised that coitus may lead to preterm labor due to the effects of prostaglandin production secondary to sexual intercourse. Stimulation of the breasts and nipples increases the body's production of oxytocin, which also can initiate labor.

A nurse is discussing preterm labor in a prenatal class. After class, a client asks the nurse to identify again the nursing strategies to prevent preterm labor. The client needs further instruction when she makes which statement?

"Cutting back on my smoking will not help my baby." Smoking is a major risk factor for preterm labor and decreased fetal weight. Clients struggling to quit should know decreasing cigarette use will help improve outcomes even if they cannot totally quit. Dehydration is a risk factor for preterm labor as is prolonged standing and remaining in one position. Infection anywhere in the body can lead to preterm labor through the inflammation pathway. While taking trips, frequent emptying of the bladder prevents infection and ambulates the woman.

A client asks the nurse why taking folic acid is so important before and during pregnancy. What should the nurse tell the client?

"Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers." Folic acid supplementation is recommended to prevent neural tube defects and anemia in pregnancy. Deficiencies increase the risk of hemorrhage during delivery as well as infection. The recommended dose prior to pregnancy is 400 mcg/day; while breastfeeding and during pregnancy, the recommended dosage is 600 to 800 mcg/day. Blood glucose levels are not regulated by the intake of folic acid. Vitamin C potentiates the absorption of iron and is also associated with blood clotting or collagen formation.

A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching?

"I should contact the health care provider if my temperature is 100.4°F (38°C) or higher." Because of the client's increased risk for infection, successful teaching is indicated when the client states that she will contact the primary care provider if her temperature is 100.4° F (38° C) or greater. The client should be instructed to monitor her temperature twice daily. The client should refrain from coitus, douching, and tub bathing, which can increase the potential for infection. Showering is permitted because water in the shower does not enter the vagina and increase the risk of infection. A fluid intake of at least 2 L daily is recommended to prevent potential urinary tract infection.

Which client statement indicates a need for additional teaching about self-care during pregnancy?

"I should sit in a hot tub for 20 minutes to relax after working." The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the first trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk of infection.

After discussing preconception needs with a nulliparous client who eats a primarily Asian diet, which client statement indicates the need for further instruction?

"If I become pregnant, I can continue to eat sushi twice a week." The client needs further instructions when she says, "If I become pregnant, I can continue to eat sushi twice a week." Raw fish, including tuna, should be avoided while the client is pregnant because of the risk of contamination with mercury and other potential teratogens. Folic acid supplements taken before the client gets pregnant and during pregnancy can help reduce the risk of neural tube defects. Steaming vegetables reduces the risk that vitamins will be lost in the cooking water. Soy products can increase the client's protein levels.

When evaluating a pregnant client's knowledge of symptoms to report immediately, which statement indicates to the nurse that the client understands the information given to her?

"If I have blurred or double vision, I should call the clinic immediately." The client stating that she should contact the clinic if she experiences blurred or double vision indicates understanding of symptoms to report. Blurred or double vision may indicate hypertension or preeclampsia. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. These symptoms don't need to be reported immediately.

A client who's 4 weeks pregnant comes to the clinic for the first prenatal visit. When obtaining the health history, the nurse explores the client's use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client?

"The client consumes no alcohol." A safe level of alcohol intake during pregnancy hasn't been established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth restriction, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose the client to complications in early pregnancy.

A client is 10 weeks pregnant and asks the nurse if feeling like she has to "go to the bathroom every 5 minutes" is normal. Which is the best response?

"The growing uterus puts pressure on the bladder so urinary frequency is normal." The client is not exhibiting any signs or symptoms of bladder infection other than urinary frequency. Urinary frequency initially most likely results from increased bladder sensitivity and compression of the bladder from the enlarging uterus. This occurs particularly during the first trimester until the uterus rises from the pelvis, thus releasing pressure on the bladder. Women are not always preoccupied with their bodily functions in the first trimester, and bladder capacity and voiding sensations vary throughout the pregnancy.

A pregnant client at about 29 weeks' gestation asks the nurse "What can I do about this dark brown line running down my stomach?" When teaching the client about this brown line, what should the nurse tell the client?

"This is a linea nigra that will fade after the baby is born." This dark brown line is a darkened pigmentation termed linea nigra. The pigmentation will fade after birth.Chadwick's sign is a bluish hue of the cervix and vagina. It is considered a normal pregnancy finding. The mask of pregnancy, called chloasma, appears as darkened areas of pigmentation on the cheeks and across the nose. It usually lightens and disappears after pregnancy.Stretch marks are reddish or purplish in color and result from the skin stretching due to the growing fetus. After birth, the marks typically become silvery white in appearance.

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?"

"This usually disappears after birth." Discoloration on the face that commonly appears during pregnancy, called chloasma (mask of pregnancy), usually fades postpartum and is of no clinical significance. The client who is bothered by her appearance 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 30-year-old client comes to the office for a routine prenatal visit. After reading the chart entry below, the nurse would prepare the client for which test?

1-Hour glucose tolerance test A 1-hour glucose tolerance test is recommended to screen for gestational diabetes if the client is obese, has glycosuria or a family history of diabetes, or lost a fetus for unexplained reasons or gave birth to a large-for-gestational-age neonate. A triple screen tests for chromosomal abnormalities. The indirect Coombs' test screens maternal blood for red blood cell antibodies. Amniocentesis is used to detect fetal abnormalities.

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:

3+ edema in the lower extremities. 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 client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse?

A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus.

During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. What is the nurse's priority intervention?

A boggy (soft and poorly contracted) fundus signals uterine atony. To correct this condition, the nurse should massage the fundus until it becomes firm and clots are expressed. Allowing a boggy fundus to persist would place the client at high risk for postpartum hemorrhage. The fundal massage should begin immediately then the nurse can check the pad. The nurse should notify the physician only if the client's fundus doesn't respond to massage.

When teaching a primigravid client about the diagnostic tests used in pregnancy, the nurse should include which information?

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. The fetal biophysical profile includes fetal breathing movements, fetal body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Normal nonstress test findings include at least two qualifying accelerations in the fetal heart rate from baseline in 20 minutes. A contraction stress test or oxytocin challenge test should be performed only on women who are at risk for fetal distress during labor. The contraction stress test is rarely performed before 28 weeks' gestation because of the possibility of initiating labor. Percutaneous umbilical cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood sample.

While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding?

A purplish blue discoloration of the vagina and cervix is termed Chadwick's sign; it is caused by increased vascularity of the vagina during pregnancy and is considered a probable sign of pregnancy. Goodell's sign, also considered a probable sign of pregnancy, refers to a softening of the cervix during pregnancy. Hegar's sign, also a probable sign of pregnancy, refers to a softening of the lower uterine segment. Melasma, the mask of pregnancy, refers to the pigmentation of the skin on the face during pregnancy. Melasma is considered a presumptive sign of pregnancy.

A pregnant woman states that she frequently ingests laundry starch. The nurse should assess the client for which condition?

All pregnant clients should be screened for pica, or the ingestion of nonfood substances, such as clay, dirt, or laundry starch. Commonly, clients who practice pica are anemic.Muscle spasms are not associated with the ingestion of laundry starch. However, they may be related to seizure disorder or seizure activity or a calcium deficiency.Lactose intolerance is not associated with the ingestion of laundry starch. Lactose intolerance would occur when the client ingests milk or milk products.Diabetes mellitus is not associated with the ingestion of laundry starch. Diabetes mellitus is associated with abnormal glucose levels, excessive thirst, and frequent voiding.

The nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?

An increased heart rate (usually greater than 100 beats/minute, depending on the client's baseline) followed by an increased respiratory rate and decreased blood pressure are among the signs of hypovolemic shock.

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.

During her first prenatal visit, a client expresses concern about gaining weight. What is the nurse's first action?

Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. Although it's important for the nurse to determine whether the client has complicating problems such as an eating disorder, doing so wouldn't be the nurse's first action. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary.

A client who is pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she is apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing:

Braxton Hicks contractions. Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. Back labor refers to labor pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green-tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.

A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?

Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea, not the presence of menses, is expected during this time. Uterine enlargement and fetal heart tones don't occur until after the first 4 weeks of pregnancy.

External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first?

Change the client's position. Variable decelerations, common after membranes rupture, usually indicate cord compression. Repositioning the client often helps to correct this fetal heart rate pattern. If repositioning is not successful, the clinician may choose to perform amnioinfusion of sterile saline solution into the uterus through a sterile catheter to help take the pressure off the cord.The nurse may wish to alert the obstetrician or nurse midwife, but the anesthesiologist is responsible for anesthesia, not for the fetus.Administering oxygen at 2 L is not helpful because pressure on the cord must be relieved first.Changing the client's position and administering oxygen often resolve the cord compression. There is no need to prepare the client for a cesarean birth at this time. A cesarean birth would be indicated for prolonged fetal distress.

A 28-year-old multigravida at 32 weeks' gestation is admitted to the hospital because of vaginal bleeding. Which action should the nurse do first?

Check fetal heart rate and maternal blood pressure. When a client is admitted with bleeding in the third trimester of pregnancy, the nurse should first assess fetal heart rate and maternal blood pressure to establish a baseline and evaluate fetal and maternal well-being.Vaginal examination is contraindicated for this client until the cause of the vaginal bleeding has been identified. For example, if the bleeding is due to abruptio placenta, a vaginal exam may cause further placental separation leading to excessive vaginal bleeding, thus placing the client at risk for hemorrhage.Any rectal manipulation, such as rectal examination or administration of an enema, is contraindicated for this client until the cause of the vaginal bleeding has been identified. For example, if the bleeding is due to abruptio placenta, an enema may cause further placental dislodgment leading to excessive vaginal bleeding and subsequently possible hemorrhage.At this point, a cesarean birth has not been planned, so witnessing a consent is not warranted.

A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. What should the nurse do next?

Continue monitoring the client and fetus. Fetal heart rate is normally between 110 and 160 bpm. The finding of a fetal heart rate at 140 bpm is within this normal range. Therefore, the nurse should continue to monitor the client and fetus.A fetal heart rate of 140 bpm is within the normal range of 110 to 160 bpm. Neither the fetus nor the mother is in any distress. Therefore, oxygen is not necessary.Because the fetal heart rate is not an abnormal reading, there is no need to notify the primary care provider, and the fetal heart rate does not need to be checked again in 5 minutes. However, continued monitoring based on agency policy is warranted.

A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these findings as suggesting that the client's husband is experiencing which complication?

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

A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note that which symptom should be reported immediately?

During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they do not require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

A client progressing through pregnancy develops constipation. What is the primary cause of this problem during pregnancy?

During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.

A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?

During the first trimester, a pregnant client is most concerned with her own needs. Because she's likely to experience discomforts of pregnancy, such as morning sickness, fatigue, and urinary frequency, the nurse should teach her how to relieve these discomforts. The nurse should teach labor breathing techniques during the second half of the pregnancy, when the client is most strongly motivated to learn them. The postpartum period is the best time to teach about infant care responsibilities and neonatal nutrition if the client didn't attend prenatal classes. Otherwise, infant care is taught during the third trimester and reinforced in the postpartum period.

Which recommendation would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn?

Eat smaller and more frequent meals during the day. Eating smaller and more frequent meals may help prevent heartburn because acid production is decreased and stomach displacement is reduced. Heartburn can occur at any time during pregnancy. Contributing factors include stress, tension, worry, fatigue, caffeine, and smoking. Certain spicy foods (e.g., tacos) may trigger heartburn in the pregnant client. The client should be advised to avoid sodium bicarbonate antacids, baking soda, sodium citrate, and fatty foods, which are high in sodium and can contribute to fluid retention. Increasing, not decreasing, fluid intake may help to relieve heartburn by diluting gastric juices. Caffeinated products such as coffee or tea can stimulate acid formation in the stomach, further contributing to heartburn.

A woman who's 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:

Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning the client about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation?

Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

Which findings are considered positive signs of pregnancy?

Fetal heartbeat and fetal movement on palpation are considered positive signs of pregnancy because they can't be caused by any other condition. Fatigue can be caused by chronic illness or anemia. Skin changes can result from cardiopulmonary disorders, estrogen-progesterone hormonal contraceptives, obesity, or a pelvic tumor. Excessive flatus or increased peristalsis can cause the perception of quickening. Breast changes can be related to hyperprolactinemia induced by sedatives, infection, prolactin-secreting pituitary tumor, pseudocyesis, or premenstrual syndrome. Abdominal enlargement can result from ascites, obesity, or uterine or pelvic tumor, and the perception of Braxton Hicks contractions can result from hematometra or a uterine tumor.

A client is at an ideal weight when she conceives. During a prenatal visit 2 months later, the client asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response?

For a client entering pregnancy in the ideal weight range, a gain of 25 to 35 lb (11.3 to 15.9 kg) is adequate to meet her needs and the needs of her fetus. Weight gain below the recommended range predisposes the client to complications during pregnancy, labor, and birth.

A client with active genital herpes is admitted to the labor and birth unit. During the first stage of labor. Which type of birth should the nurse anticipate for this client?

For a client with active genital herpes, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it's inappropriate for this client.

The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding?

Greenish-colored amniotic fluid is caused by the passage of meconium, usually secondary to a fetal insult during labor. Meconium passage also may be related to an intact gastrointestinal system of the neonate, especially those neonates who are full term or of postdate gestational age. Amnioinfusion may be used to treat the condition and dilute the fluid. Cloudy amniotic fluid is associated with an infection caused by bacteria or a sexually transmitted disease. Severe yellow-colored fluid is associated with Rh incompatibility or erythroblastosis fetalis.

The primary health care provider (HCP) orders 1,000 mL of Ringer's lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute? Record your answer as a whole number.

Gtts/min = (12 gtts/1 mL) X (1000 mL/8 hr) X (1 hr/60 min) = 25 gtts/min.

After instructing a pregnant client about third trimester edema, the nurse determines that the client needs further instruction when the client makes which statement?

If the client experiences swelling in the face or hands or has any visual disturbances, she needs to report these symptoms promptly because they may indicate pregnancy-induced hypertension.Swelling of the feet and ankles is a common discomfort of pregnancy.The client should continue to drink six to eight glasses of a noncaffeinated beverage or water daily to prevent dehydration.The client should elevate her feet whenever possible and avoid prolonged standing or sitting to promote adequate venous return.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

Immediately after a spontaneous rupture of the membranes, the nurse should listen to the fetal heart rate to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. Fetal heart rate should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount, and odor of the amniotic fluid should be noted.Although the optimal position for the client is side lying, this is not a priority at this time.The client is not having a precipitous birth with the fetal head at ?1 station. Therefore, preparing the client for a cesarean birth is unnecessary.Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time.

The fetus of a multigravid client at 38 weeks' gestation is determined to be in a frank breech presentation. The nurse describes this presentation to the client as which fetal part coming in contact with the cervix?

In a frank breech, the buttocks alone are at the cervix, while the knees are extended to rest on the chest. In a cephalic presentation, the head is the fetal body part first coming in contact with the cervix. Both feet at the cervix is termed double footling breech. In a shoulder presentation, one of the shoulders (actually the acromion process) presents to the cervix. Typically, the fetus is lying horizontally (transverse lie).

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?

Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.

A 32-year-old primigravida at 39 weeks' gestation is admitted to the hospital in active labor. While the nurse performs Leopold's maneuvers, the client asks why these maneuvers are being done. The nurse explains that the major purpose of these maneuvers is to determine which factor?

Leopold's maneuvers, four techniques of abdominal palpation performed between contractions and after the client empties her bladder, assist in identifying fetal presentation and position. Leopold's maneuvers are often performed before initial auscultation of the fetal heart rate.In certain situations, the maneuvers can determine deviations, such as multifetal pregnancy or a large fetus. However, this condition is usually confirmed through ultrasound procedures.Leopold's maneuvers are not used to determine estimated gestational age. Estimated gestational age is determined by ultrasound.Leopold's maneuvers do not determine contraction intensity because they are performed between contractions. Rather, contraction intensity is determined by palpation and electronic uterine monitoring.

At an initial prenatal visit the client tells the nurse that her last menstrual period started on April 14th. Using Naegele's rule, the nurse determines the woman's estimated due date is when?

Naegele's rule is a mathematical equation that uses a woman's last menstrual period (LMP) to estimate a pregnant client's dues date. The formula is LMP + 7 days ? 3 months. Here the LMP is:April 14th + 7 days = April 21st;April 21st ? 3 months = January 21st.

A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using which approach?

Saline nose drops are a natural remedy and can alleviate the discomfort.Clients who are pregnant should not take any medications without consulting the health care provider; therefore, oral antihistamines and oral decongestions should be avoided.Ice packs are not helpful in alleviating congestion. Warm moist towels might be helpful.

After a preparation for parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. What is the best advice for the nurse to give the client?

Schedule an appointment at the clinic for an examination. Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge with local itching is associated with infection (e.g., Trichomonas vaginalis). The client's symptoms must be further assessed by a health professional because the client needs treatment for this condition. T. vaginalis infection is commonly treated with metronidazole; however, this drug is not used in the first trimester. In the first trimester, the typical treatment is topical clotrimazole. Although a yeast infection is associated with vaginal itching, the vaginal discharge is cheese-like. Furthermore, because the client may have a serious vaginal infection, over-the-counter medications are not advised until the client has been evaluated. Douching is not recommended during pregnancy because it would predispose the client to an ascending infection. The client is not exhibiting signs and symptoms of preterm labor, such as contractions or leaking fluid. And although the client's reported symptoms are suggestive of a T. vaginalis infection, which can lead to preterm labor and premature rupture of the membranes, further evaluation is needed to confirm the cause of the infection.

An obstetric ultrasound reveals that the client's fetus has spina bifida. The mother is concerned about raising a child with a congenital abnormality and she starts to cry. Which response by the nurse is best?

Sit at her bedside and allow the client to express her feelings. The mother has just been given unexpected news. The nurse should provide emotional support by sitting with the client and allowing her to express her feelings and concerns. The nurse shouldn't tell a client what to do. The client needs information to make her own informed decision. Recommending a pediatrician is premature because the client just received the ultrasound results. The nurse shouldn't discuss birth at this time. The preferred birth method for a fetus with spina bifida is cesarean birth, which prevents damage to the open spinal cord defect as the fetus descends through the birth canal.

A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 ml normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using a whole number.

Solve as follows: (500 ml/20 g) X 2 g/h = 50 ml/hr.

A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask which question?

TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus — agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.

A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which instruction would be most helpful?

Take frequent rest periods with the legs elevated above the hips. The client with leg varicosities should take frequent rest periods with the legs elevated above the hips to promote venous circulation. The client should avoid constrictive clothing, but support hose that reach above the varicosities may help alleviate the pain. Contracting and relaxing the feet and ankles twice daily is not helpful because it does not promote circulation. Taking a leave of absence from work may not be possible because of economic reasons. The client should try to rest with her legs elevated or walk around for a few minutes every 2 hours while on the job.

The third stage of labor ends

The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.

When the nurse instructs a pregnant client with a history of varicose veins about strategies to promote comfort, which client statement indicates that the teaching has been successful?

The enlarging uterus exerts pressure on blood vessels carrying blood to and from the lower part of the body, especially the extremities, predisposing the client to varicosities. Prevention and management of varicosities includes lying down with feet elevated several times a day to promote venous return and avoiding anything that constricts the legs or thighs, such as round garters or knee-high hose.Supportive hose or elastic stockings may be helpful but should be applied as soon as the client awakens in the morning.Restriction of milk intake has no effect on varicosities.Knee-high stockings could cause constriction and should be avoided.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first?

The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by completing a vaginal exam to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?

The fetal heart rate monitoring strip shows late decelerations, which indicate uteroplacental circulatory insufficiency and can lead to fetal hypoxia and acidosis if the underlying cause is not corrected. The client would be turned onto her left side to increase placental perfusion and decrease contraction frequency. In addition, the intravenous fluid rate may be increased and oxygen administered. The right lateral, supine, and prone positions do not increase placental perfusion.

During a nonstress test (NST), a nurse notes three fetal heart rate (FHR) increases of 20 beats/minute, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest?

The fetus is not in distress at this time. In an NST, reactive (favorable) results include two to three FHR increases of 15 beats/minute or more, each lasting 15 seconds or more and occurring with fetal movement. An oxytocin challenge test is performed to stimulate uterine contractions and evaluate the FHR. If results are inconclusive, a nipple stimulation contraction test may be ordered. A nonreactive result occurs when the FHR doesn't rise 15 beats/minute or more over the specified time; a nonreactive result may indicate fetal hypoxia.

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of the fetus. The client's BPP score is 8. What does this score indicate?

The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may be repeated if the score isn't within normal limits.

During a prenatal visit, a nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age?

The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?

The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes firmer and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage.

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 Nägele's rule, what date should the nurse record as the estimated date of delivery (EDD)?

The nurse can calculate EDD using Nägele'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 primary care provider has prescribed nalbuphine hydrochloride 10 mg intravenously for a client in active labor. The pharmacy supplies a vial labeled as 50 mg in a 5-mL vial. How many milliliters should the nurse administer? Record your answer using a whole number.

The nurse should administer 1 mL of the solution, calculated as follows:50 mg/5 mL = 10 mg/x.50 x = 50 mL.x = 1 mL.

Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?

The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. Regular contractions 3 minutes apart and 1 minute in duration along with an urge to push, as exhibited in the second client, indicate a pending delivery. Priority should be assigned to this client. Leaking amniotic fluid that appears to be clear, as exhibited in the first client, doesn't indicate that contractions are about to begin. This client is less of a priority.

A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), what should the nurse do?

The nurse should turn the client to the side to reduce pressure on the abdominal aorta. The IV fluid rate would be increased, not decreased. There is no information indicating the client has a full bladder or requires a vaginal examination.

After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which hormone is produced by the placenta?

The placenta does not produce testosterone. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. The hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi.

A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her?

This symptom is normal and results from the fetus exerting pressure on the bladder. During the first trimester, hormonal changes and uterine pressure on the bladder cause urinary frequency and urgency. During the second trimester, when the uterus rises out of the pelvis, urinary symptoms abate. However, as term approaches, pressure on the bladder by the presenting part of the fetus again causes urinary frequency and urgency. Urinary frequency isn't abnormal unless accompanied by other urinary symptoms, such as burning and pain. Fluids shouldn't be limited during pregnancy. Urinary frequency doesn't subside after the presenting part is engaged. Instead, the presenting part exerts pressure on the bladder.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

To assess the frequency of the client's contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifies the peak of a contraction.

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure?

Variable decelerations are associated with compression of the umbilical cord. The nurse should alter the client's position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal birth, may result in transient bradycardia. Compression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations.

Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first?

When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.

Using Nägele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of birth is what date?

When using Nägele's rule to determine the estimated date of childbirth, the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days. This means the client's estimated date is February 17.

A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone?

Widely used pregnancy tests detect hCG in the blood and urine by immunologic tests specific for the beta subunit of hCG. Human placental lactogen, human chorionic thyrotropin, and estradiol are hormones produced by the placenta; however, they aren't used to detect pregnancy.

A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect?

bilateral dependent edema As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.

A nurse is caring for a client receiving I.V. magnesium sulfate. Which drug is the antidote for magnesium toxicity?

calcium gluconate The nurse should anticipate administering 10 ml of 10% calcium gluconate by I.V. push over 3 to 5 minutes as a calcium gluconate antidote for magnesium toxicity. Hydralizine/hydralazine is given for sustained elevated blood pressures in clients with preeclampsia. Naloxone is used to correct opioid toxicity. RHo(D) immune globulin is given to clients with Rh-negative blood to prevent antibody formation from Rh-positive fetuses.

A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for:

changes in cervical effacement and dilation after 1 to 2 hours. True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours.

A 24-year-old client admitted to the hospital is suspected of having an ectopic pregnancy. On admission, which factor would be most important to assess?

date of last menstrual period Although it may be important to obtain information from a client with suspected ectopic pregnancy concerning when she last had intercourse, whether she is taking birth control pills, and whether she has been pregnant previously, it is most important to determine the date of her last menstrual period and if she has experienced amenorrhea. Such information helps establish an accurate diagnosis. Usually the client with an ectopic pregnancy suspects or knows that she is pregnant, having missed one or two menstrual periods. However, if the client's menstrual cycle is irregular, she may be unaware that she is pregnant.Obtaining information about sexual practices would be important for the sexual history and helping to identify the frequency of sexual intercourse and possibility of pregnancy. However, this information is only helpful after obtaining the date of the client's last menstrual period.Information about birth control methods, such as use of a diaphragm or type of oral contraceptive, is important once the date of the client's last menstrual period is determined.

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?

estimate the fetal growth 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. 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's maneuver will determine fetal position, but is not typically done in the second trimester when the fetus is still freely moving.

When evaluating a pregnant client's fundal height, the nurse should measure in which way?

from the symphysis pubis notch to the highest level of the fundus To measure fundal height, the nurse should stretch a measuring tape over the client's enlarged abdomen and measure from the symphysis pubis notch to the highest level of the fundus, determined by palpation. Measuring across the abdomen and measuring from the symphysis pubis to the umbilicus are incorrect procedures for measuring fundal height. A pelvimeter is used to evaluate the size of the maternal pelvis for delivery, not fundal height.

A client has her first prenatal visit at 15 weeks' gestation. The client weighs 144 lb (65.5kg) and states this is a 4-pound weight gain. Which assessment finding requires further investigation?

fundal height of 18 cm Fundal height (in centimeters) should roughly equal the number of weeks' gestation. This client should have a fundal height of 15 to 16 cm. A height of 18 cm could be indicative of many things, including multiples or polyhydramnios. The blood pressure, urine, and weight findings are within normal limits for this client. During the first trimester, weight gain should average between 1 and 4.5 pounds (0.5-2 kg).

A pregnant client comes to the facility for the first prenatal visit. After obtaining a health history and performing a physical examination, the nurse reviews the client's laboratory test results. Which findings suggest iron deficiency anemia?

hemoglobin 9 g/dL (90 g/L); hematocrit 30% With iron deficiency anemia, the hemoglobin level is below 12 g/dL (120 g/L) and hematocrit drops below 33%.

A client who is 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus may be at risk for:

low birth weight. The risk of intrauterine growth restriction may increase with the number of cigarettes a pregnant woman smokes. Neural tube defects (such as spina bifida), cardiac abnormalities (such as tetralogy of Fallot), and renal disorders (such as hydronephrosis) are associated with multifactorial genetic inheritance, not maternal cigarette smoking.

A primigravid client with diabetes at 39 weeks' gestation is seen in the high-risk clinic. The primary health care provider (HCP) estimates that the fetus weighs at least 10 lb (4,500 g). The client asks, "What causes the baby to be so large?" The nurse's response is based on the understanding that fetal macrosomia is usually related to which factor?

maternal hyperglycemia Maternal hyperglycemia and poor control of the mother's diabetes mellitus have been implicated in fetal macrosomia. When the mother is hyperglycemic, large amounts of amino acids, free fatty acids, and glucose are transferred to the fetus. Although maternal insulin does not cross the placenta, the fetal pancreas responds by hypertrophy of the islet cells of the pancreas. The islet cells produce large amounts of insulin, which acts as a growth hormone. A family history of large infants usually is not the reason for large-for-gestational-age fetuses in diabetic mothers. Maternal hypertension is associated with small-for-gestational-age fetuses because of vasoconstriction of the maternal and placental blood vessels.

A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding?

normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation Although most multiparous women experience quickening at about 17½ weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect. Detecting movement early does not suggest a twin pregnancy. If the multiparous client does not experience quickening by 20 weeks' gestation, further investigation is warranted, because the fetus may have died, the client has a hydatidiform mole, or the pregnancy dating is incorrect. There is no evidence that the client's expected date of birth is erroneous.

A nurse is providing dietary teaching to a pregnant client. To help meet iron needs, the nurse should advise the client to eat:

spinach and beef. Common food sources of iron include spinach, beef, liver, prunes, pork, broccoli, legumes, and whole wheat breads and cereals. Grains are good sources of carbohydrates; milk is high in vitamin D; and fish, eggs, and milk are high in protein. Tomatoes and citrus fruits are high in vitamins A and C.

A nurse obtains the antepartum history of a client who is 6 weeks pregnant. Which finding is a concern?

the client's consumption of six to eight cans of beer on weekends Consuming any amount or type of alcohol isn't recommended during pregnancy because it increases the risk of fetal alcohol syndrome or fetal alcohol effect. The nurse should teach the client about these risks. If the client is accustomed to moderate exercise, she may continue to engage in low-impact aerobics during pregnancy. Eating frequent, small meals helps maintain the client's energy level by keeping the blood glucose level relatively constant. Taking a multivitamin supplement daily and eating a balanced diet are recommended during pregnancy.

A client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client should lie on her left side when resting or sleeping in the later stages of pregnancy?

to prevent compression of the vena cava The weight of the pregnant uterus is sufficiently heavy to compress the vena cava, which could impair blood flow to the uterus, possibly decreasing oxygen to the fetus. The client may experience supine hypotension syndrome (faintness, diaphoresis, and hypotension) from the pressure on the inferior vena cava. The side-lying position puts the weight of the fetus on the bed, not on the woman. The side-lying position has not been shown to prevent fetal anomalies, nor does it facilitate bladder emptying or digestion.