antepartum

The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which foods can the client add to the daily diet to decrease the risk of neural tube defects? Select all that apply. 1. Black beans and rice 2. Fortified breakfast cereal and milk 3. Medium baked sweet potato 4. Peanut butter on whole wheat toast 5. Raw carrots with cheese dip

Folic acid, or folate, is a water-soluble, B-complex vitamin necessary for red blood cell production. Pregnant women and those attempting pregnancy need a minimum of 400 mcg of folic acid per day to decrease the chance of fetal neural tube defects (eg, spina bifida, anencephaly). Most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid can come from the diet. Leafy green vegetables are the best dietary sources of folic acid. However, other appropriate food choices include cooked beans, rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving (Options 1, 2, and 4). (Option 3) Sweet potatoes provide vitamin A, vitamin C, and minerals to the diet but no folic acid. (Option 5) Raw carrots are a dietary source of vitamin A, vitamin C, and minerals, but not of folic acid.

The nurse performs initial assessments of four clients in a prenatal clinic. Which client findings are abnormal and require further assessment? 1. Client at 9 weeks gestation with a normal BMI and a weight gain of 2 lb (1 kg) from pre-pregnancy weight(4%) 2. Client at 15 weeks gestation with headaches relieved by acetaminophen(6%) 3. Client at 19 weeks gestation with bleeding gums after brushing and flossing teeth(25%) 4. Client at 20 weeks gestation with an increase in diastolic blood pressure of 15 mm Hg since last visit(62%)

Physiologic decreases in systemic vascular resistance during pregnancy cause a steady, slight decrease in blood pressure(BP) beginning in the first trimester and reaching the lowest point around 24-32 weeks gestation. In the third trimester, BP gradually returns to pre-pregnancy baseline. Monitoring BP during pregnancy assists in the detection of hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, preeclampsia, eclampsia). Some clients with only mildly elevated BP may develop eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/early-pregnancy measurements, even in the absence of hypertension (ie, ≥140/90 mm Hg), is a deviation from normal physiologic BP responses in pregnancy and requires further assessment for other signs/symptoms (eg, proteinuria, headache, right upper quadrant pain) (Option 4). (Option 1) Early in the first trimester, minimal weight gain (ie, 1-4 lb [0.5-1.8 kg]) is expected for clients with a normal BMI. (Option 2) Occasional headaches relieved by acetaminophen may be normal for some pregnant clients. Severe, frequent, or worsening headaches require further assessment. (Option 3) Hyperemic gums are common in pregnancy and may be susceptible to mild bleeding during brushing. Gentle cleaning with a soft toothbrush may help prevent bleeding.

A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. She reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. What actions should the nurse take? Select all that apply. 1. Anticipate emergent cesarean birth 2. Apply continuous external fetal monitoring 3. Assess routine vital signs every 4 hours 4. Draw blood for type and crossmatch 5. Initiate IV access with a 22-gauge catheter

Placental abruption occurs when the placenta separates prematurely from the uterine wall, causing hemorrhage beneath the placenta. Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous abruption, and preterm premature rupture of membranes. Symptoms and their severity depend on extent of abruption and include abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie, excessive uterine contractions), with or without fetal distress, is often present, and continuous fetal monitoring is necessary (Option 2). A type and crossmatch should be drawn as treatment may include blood transfusion (Option 4). In severe cases, emergent cesarean birth is indicated (Option 1). Although blood loss is maternal, the loss of functional placental surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death. (Option 3) Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) as client condition can decline rapidly. In this acute scenario, assessment of vital signs every 4 hours is not sufficient. (Option 5) Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated.

A pregnant client in the first trimester tells the clinic nurse she will be traveling to an area with a known Zika virus outbreak and expresses concern regarding disease transmission. Which statement by the nurse is most appropriate? 1. "If you experience Zika symptoms, notify your health care provider."(1%) 2. "Take precautions against mosquito bites throughout the trip."(33%) 3. "You are not far enough along for the Zika virus to affect your baby."(0%) 4. "You should consider postponing your trip until after you have the baby."(64%)

Zika virus is transmitted via mosquitoes, sexual contact, and infected bodily fluids. Zika causes viral symptoms (eg, low-grade fever, arthralgias) and has been shown to cause microcephaly, developmental dysfunction, and encephalitisin babies born to Zika-infected women. Women who are attempting to conceive and those who are pregnant are encouraged to avoid travel to areas affected by Zika until after birth (Option 4). For clients currently living in a Zika-affected area, proper mosquito precautions (eg, insect repellant containing DEET) and safe sex practices (eg, barrier methods) should be utilized, and routine Zika testing may be provided. (Option 1) Although this statement is true, it does not provide education on avoiding Zika infection. Waiting until symptoms are present does not address preventing fetal exposure and possible birth defects. (Option 2) Current guidelines recommend that pregnant women avoid travel to Zika-affected areas completely. In addition, mosquitoes are not the only mode of transmission for the virus. (Option 3) Zika virus can affect women in all stages of pregnancy.

The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of teaching? 1. "I need to be on bed rest for the duration of my pregnancy."(18%) 2. "I will notify my health care provider if I start having low back aches."(41%) 3. "Pelvic pressure is to be expected after cerclage placement."(22%) 4. "The cerclage will be removed once my baby is at 28 weeks."(17%)

A cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second trimester loss or premature birth. A heavy suture is placed transvaginally or transabdominally to keep the internal cervical os closed. Placement occurs at 12-14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option 2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36-37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates).

The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement by the client indicates an appropriate understanding about weight gain? 1. "I should gain 10-15 lb (4.5-6.8 kg) during the first trimester."(14%) 2. "I should gain a total of about 30 lb (13.6 kg) during my pregnancy."(65%) 3. "I should gain no more than 0.5 lb (0.2 kg) per week during the third trimester."(17%) 4. "If I gain <20 lb (9.1 kg) during pregnancy, it will be easier to lose weight postpartum."(2%)

Appropriate weight gain during pregnancy decreases risks to the client and fetus. Expected weight gain is determined by prepregnancy BMI. Underweight clients need to gain more weight (1 lb [0.5 kg] per week) during the second and third trimesters of pregnancy than obese clients (0.5 lb [0.2 kg] per week). However, weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. With a prepregnancy BMI of 21 kg/m2, this client has an appropriate weight and should gain 25-35 lb (11.3-15.9 kg)over the course of the pregnancy (Option 2). (Option 1) Weight gain during the first trimester should be approximately 1.1-4.4 lb (0.5-2.0 kg). A 10 lb (4.5 kg) weight gain during the first three months of pregnancy would be excessive for any client. (Option 3) A client of appropriate weight should gain approximately 1 lb (0.5 kg) per week during the second and third trimesters of pregnancy. A weight gain of only 0.5 lb (0.2 kg) per week is recommended for obese clients. (Option 4) A weight gain of <20 lb (9.1 kg) during pregnancy is inadequate for a client of appropriate weight. Restricting weight gain increases the fetus' risk for low birth weight (<5.5 lb [2500 g]) and preterm birth.

Which meal should the nurse recommend for a pregnant client at 13 weeks gestation? 1. Baked chicken, turnip greens, peanut butter cookie, and grape juice(62%) 2. Baked swordfish, fries, baked apples, and fat-free milk(4%) 3. Chilled ham and cheese sandwich, broccoli, orange slices, and water(18%) 4. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water(14%)

During pregnancy, it is important for the client to consume a balanced diet with appropriate nutrients, vitamins, and minerals. Foods containing folic acid, protein, whole grains, iron, and omega-3 fatty acids are especially important. Due to the risk for bacterial contamination (eg, Listeria, toxoplasmosis), pregnant clients should avoid consuming unpasteurized milk products, unwashed fruits and vegetables, deli meat and hot dogs (unless heated until steaming hot), and raw fish/meat. They should also avoid intake of fish high in mercury (eg, shark, swordfish, king mackerel, tilefish). (Option 2) This meal contains swordfish, which is high in mercury and should be avoided during pregnancy. (Option 3) This meal contains cold deli meat, which should be avoided during pregnancy due to the risk of listeriosis from Listeria monocytogenes. (Option 4) Liver should be avoided during pregnancy due to high amounts of vitamin A. Although liver is a good source of iron, the excessively high amounts of vitamin A can be teratogenic.

A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? Select all that apply. 1. Additional ultrasound around 36 weeks gestation 2. Clearance for sexual activity if bleeding stops 3. Discharge home if bleeding stops and fetal status is reassuring 4. Scheduled cesarean birth before onset of labor 5. Weekly vaginal examinations to assess for cervical change

In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs. As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option 1). (Options 2 and 5) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended.

The nurse is performing assessments of several clients during routine prenatal visits. Which client should the nurse discuss with the health care provider first? 1. Client at 30 weeks gestation with darkened patches of skin on the face(6%) 2. Client at 32 weeks gestation with painless, flesh-colored bumps on the perianal area(54%) 3. Client at 34 weeks gestation with intense itching on the hands and feet that worsens at night but no rash(31%) 4. Client at 38 weeks gestation with stretch marks on the abdomen that have become reddened and pruritic(6%)

Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash. Itching often involves the hands and feet and worsens at night. This condition increasesthe risk of intrauterine fetal demise and requires priority assessment by the health care provider (Option 3). Management includes laboratory testing (eg, elevated bile acids), fetal surveillance (eg, biophysical profile, nonstress test), medication (ie, ursodeoxycholic acid), and labor induction around 37 weeks gestation. Intrahepatic cholestasis of pregnancy begins to resolve after birth. (Option 1) Chloasma (ie, melasma, mask of pregnancy) is a hormonally stimulated increase in pigmentation over the bridge of the nose and cheeks that usually appears in the second trimester; it is benign and fades postpartum. (Option 2) Fleshy, nontender bumps on genital/anal areas are characteristic of condylomata acuminata (ie, anogenital warts) caused by human papillomavirus. Treatments (eg, trichloroacetic acid) are available for removal of warts in pregnancy, but it is not a priority. (Option 4) Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a dermatologic complication that causes discomfort but is not harmful to the client. Pruritic, raised lesions form within abdominal striae, spare the umbilicus, and may spread to the thighs, arms, legs, and back.

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting(0%) 2. Second-trimester client with dysuria and urinary frequency(6%) 3. Second-trimester client with obesity reporting decrease in fetal movement(47%) 4. Third-trimester client with right upper quadrant pain and nausea(45%)

Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting,and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. (Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority.

The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios. Considering the client's indication for induction, what should the nurse anticipate? 1. Additional neonatal personnel present for birth(37%) 2. Intermittent fetal monitoring during labor(26%) 3. Need for forceps-assisted vaginal birth(13%) 4. Need for uterotonic drugs for postpartum hemorrhage(21%)

Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord compression and promote lung development. Oligohydramnios is a condition characterized by low amniotic fluid volume. This can occur due to fetal kidney anomalies (eg, renal agenesis or urine flow obstruction) or fluid leaking through the vagina (eg, undiagnosed ruptured membranes). Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal outline that is easily palpated through the maternal abdomen should raise suspicion for oligohydramnios. Ultrasound confirms the diagnosis. Major complications of oligohydramnios are: Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated amniotic fluid. Therefore, additional neonatal personnel should attend the birth in anticipation of possible resuscitation (Option 1). Umbilical cord compression - continuous (not intermittent) fetal monitoring should be applied to monitor for variable decelerations (Option 2). (Option 3) Operative vaginal birth (ie, use of forceps or vacuum) may be indicated due to prolonged second-stage labor or fetal distress. Oligohydramnios does not increase the likelihood of operative vaginal birth. (Option 4) Polyhydramnios (excessive amniotic fluid volume) is a risk factor for postpartum hemorrhage due to overdistension of the uterus. Oligohydramnios is not associated with postpartum hemorrhage.

The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider? 1. Client at 24 weeks gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29%(41%) 2. Client at 26 weeks gestation whose 1-hour (50 g) oral glucose challenge test result is 120 mg/dL (6.7 mmol/L)(4%) 3. Client at 36 weeks gestation with blood pressure of 125/85 mm Hg and trace protein detected on urine dipstick(29%) 4. Client at 37 weeks gestation with a WBC count of 13,000/mm3 (13.0 x 109/L)(23%)

Anemia is a common complication of pregnancy, sometimes due to iron deficiency. During the second half of pregnancy, the fetus begins to store iron in preparation for extrauterine life and depletes maternal iron stores. Hemoglobin <11 g/dL (110 g/L) in the first or third trimester or <10.5 g/dL (105 g/L) in the second trimester is considered low. The nurse should evaluate a client with a hemoglobin of 9 g/dL (90 g/L) for symptoms of anemia (eg, fatigue, shortness of breath) and notify the health care provider because the client may require additional testing (eg, complete blood count, serum ferritin) and iron supplementation (Option 1). (Option 2) A 1-hour (50 g) oral glucose challenge test screens clients for gestational diabetes and is considered abnormal if blood glucose is ≥130-140 mg/dL (7.2-7.8 mmol/L). (Option 3) Protein is not normally detected in the urine, but large amounts of protein in the urine (eg, ≥300 mg/24 hours, ≥1+ on urine dipstick) along with elevated blood pressure (eg, ≥140/90 mm Hg) may indicate preeclampsia. Trace protein is likely due to specimen contamination or recent illness. (Option 4) During pregnancy, it is normal for the WBC count to increase, even in the absence of infection.

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? 1. Client has not been taking prenatal vitamins(13%) 2. Client is taking lisinopril to control hypertension(53%) 3. Client reports a whitish vaginal discharge(3%) 4. Client reports mild cramping pain in the lower abdomen(29%)

Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg, losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic, leading to fetal renal and cardiac abnormalities, and are contraindicated in all stages of pregnancy. (Option 1) Prenatal supplements, especially folic acid and iron, are recommended during pregnancy. Although important, this is not a priority over discontinuing ACE inhibitors. (Option 3) Leukorrhea, a whitish vaginal discharge, is common during the prenatal period. The client should be instructed to call the health care provider if the discharge is accompanied by other signs or symptoms, such as a foul odor, redness, or itching. (Option 4) As the uterus enlarges, cramping may occur in the lower abdomen and inguinal region. This common finding can be caused by stretching of the round ligaments, and is usually not concerning in the absence of vaginal bleeding.

The nurse is obtaining a client's history during an initial prenatal visit. The client's last menstrual period was from March 1 to March 5. Unprotected intercourse occurred on March 15. Slight vaginal spotting was noted on March 23. The client's menstrual cycles are regular and 28 days long. Using the Nägele rule, what is the estimated date of birth? 1. December 8(54%) 2. December 12(24%) 3. December 22(13%) 4. December 30(7%)

Establishing an estimated date of birth (EDB) is important because many decisions and interventions during pregnancy are based on this information (eg, labor induction, diagnosing preterm labor). Methods to determine EDB include the Nägele rule, ultrasound, fundal height measurement, and fetal heart rate auscultation via handheld Doppler monitor (at ~10 weeks gestation). The Nägele rule uses a standard formula based on the last normal menstrual period (LMP) to determine EDB based on a 28-day menstrual cycle: EDB = (LMP − 3 months) + 7 days. First day of LMP: March 1 Subtract 3 months: December 1 Add 7 days: December 8 This client's EDB is December 8 (Option 1). (Option 2) December 12 was calculated using the last day of the client's menses (March 5). Menses length can vary, so the last day of menses cannot be used to accurately calculate EDB. (Option 3) December 22 was calculated based on the likely date of conception (March 15). Because the timing of ovulation varies by client, this is not an accurate method for calculating EDB. (Option 4) December 30 was calculated using the client's report of vaginal spotting (March 23). Light vaginal spotting may be noted when the trophoblast implants into the endometrium. Many clients confuse "implantation bleeding" for an unusually light period. Dating a pregnancy from this day is inaccurate.

The nurse is assessing a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first? 1. "I am not sleeping as well due to cramps in my calves at night."(29%) 2. "I have noticed less kicking movements as the baby grows bigger."(49%) 3. "Over the last few weeks, I have not been able to wear any of my shoes."(17%) 4. "Sometimes I feel short of breath after walking up a flight of stairs."(3%)

Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However, fetal movements should not decrease as the fetus increases in size. Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal death (Option 2). The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (eg, nonstress test). (Option 1) Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying pressure to nerves affecting calf muscles. Home interventions include stretching legs, massaging calves, and increasing fluid intake. (Option 3) Dependent edema in the lower extremities is common in the third trimester due to decreased venous return (gravid uterus pressure on vena cava), especially with prolonged sitting/standing. This is not a priority over decreased fetal movement. (Option 4) As the uterus rises in the third trimester, the diaphragm is prevented from allowing full lung expansion, causing dyspnea, especially with exertion.

The nurse is providing teaching to a prenatal client about the 1-hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further teaching? 1. "Fasting is required before the 1-hour glucose challenge test."(33%) 2. "One blood sample is obtained at the end of the test."(28%) 3. "The test includes drinking a 50-g glucose solution."(15%) 4. "The test's purpose is to screen for gestational diabetes, not diagnose it."(22%)

Gestational diabetes mellitus (GDM) is diagnosed in clients who have impaired blood glucose (BG) regulation due to physiologic pregnancy changes (eg, rising BG levels, insulin resistance). GDM screening occurs at 24-28 weeks gestation. If GDM is diagnosed, management includes nutritional counseling and, if needed, pharmacologic therapy. Two-step GDM testing begins with a screening test: the 1-hour glucose challenge test (GCT). The 1-hour GCT can be performed any time of day and does not require fasting (Option 1). If the client's serum BG is <140 mg/dL (7.8 mmol/L), GDM is unlikely, and the client requires no further testing. If serum BG is ≥140 mg/dL (7.8 mmol/L), the client requires a 2- or 3-hour glucose tolerance test (GTT) to diagnose GDM. (Options 2 and 3) For the 1-hour GCT, the nurse draws one blood sample an hour after ingestion of a 50-g glucose solution (eg, glucola). In contrast, a 2- or 3-hour GTT requires the nurse to obtain fasting and hourly blood samples. (Option 4) The 1-hour GCT is a screening test only.

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect? 1. Abdominal pain and low-grade fever(39%) 2. Blood pressure ≥140/90 mm Hg(16%) 3. High urine protein level(12%) 4. Moderate to high urine ketones(31%)

Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy that usually leads to considerable weight loss (ie, ≥5% of prepregnancy weight), fluid and electrolyte imbalances (eg, hypokalemia), and nutritional deficiencies. Clients with HG may require hospitalization for IV fluid replacement and antiemetic therapy. Routine laboratory assessment for HG includes urinalysis dipstick testing to monitor the client's health status. Expected findings include an elevated urine specific gravity and ketonuria (Option 4). Urine specific gravity increases when urine is concentrated due to dehydration, and ketones are a by-product of the fat breakdown that occurs in starvation states. (Option 1) Abdominal pain and fever are not expected findings with HG. Such findings, especially when associated with nausea and vomiting, should prompt further investigation for other causes (eg, gastroenteritis). (Option 2) Elevated blood pressure (≥140/90 mm Hg) is not an expected finding in clients with HG due to dehydration and hypovolemia. Instead, hypotension and tachycardia are expected. (Option 3) Proteinuria is not an expected finding in clients with HG but is associated with kidney disease or preeclampsia

A client at 35 weeks gestation is admitted to the labor and delivery unit for severe pre-eclampsia. She is started on IV magnesium sulfate for seizure prophylaxis. Which of the following signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply. 1. 0/4 patellar reflex 2. Blood pressure of 156/84 mm Hg 3. Client voiding 600 mL in 8 hours 4. Respirations of 10/min 5. Serum magnesium level of 8.0 mEq/L (4 mmol/L)

IV magnesium sulfate is administered for seizure (eclampsia) prophylaxis in pregnant clients with pre-eclampsia. A loading dose of 4-6 g of magnesium sulfate, followed by a maintenance dose of 1-2 g/hr, helps achieve therapeuticmagnesium levels of 4-7 mEq/L (2.0-3.5 mmol/L). Magnesium toxicity may occur when magnesium levels are >7 mEq/L (3.5 mmol/L), which causes central nervous system depression and blocks neuromuscular transmission (Option 5). Absent or decreased deep tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs, scored on a scale of 0 to 4+, should be frequently assessed during magnesium sulfate infusion; normal findings are 2+ (Option 1). If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression (<12 breaths/min), followed by cardiac arrest (Option 4). Administration of calcium gluconate (antidote) is recommended in the event of cardiorespiratory compromise. (Option 2) Hypertension is a sign of pre-eclampsia, not of magnesium toxicity. Hydralazine (Apresoline) and/or labetalol are used to lower blood pressure if needed (ie, when >160/110 mm Hg). (Option 3) Urine output <30 mL/hr is a sign that magnesium toxicity may be likely, as magnesium is excreted through the urine.

The obstetric nurse is reviewing phone messages. Which client should the nurse call first? 1. Client at 18 weeks gestation taking ceftriaxone and reporting mild diarrhea(10%) 2. Client at 22 weeks gestation with twins who is taking acetaminophen twice a day(23%) 3. Client at 28 weeks gestation taking metronidazole and reporting dark-colored urine(27%) 4. Client at 32 weeks gestation taking ibuprofen for moderate back pain(38%)

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin, naproxen) inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or to reduce fever. NSAIDs are pregnancy category C in the first and second trimesters and pregnancy category D in the third trimester. NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus arteriosus in the fetus (Option 4). During the first and second trimesters, NSAIDs should be taken only if benefits outweigh risks and under the supervision of a health care provider (HCP). (Option 1) Beta lactam antibiotics (eg, amoxicillin, ceftriaxone [Rocephin]) are pregnancy category B. Diarrhea is a common side effect of beta lactams. Although diarrhea should be reported to the HCP, as it could indicate pseudomembranous (Clostridium difficile) colitis or lead to dehydration if prolonged, this client is not the priority. (Option 2) Acetaminophen (pregnancy category B) is a common pain reliever and/or fever reducer used during pregnancy. Acetaminophen intake should not exceed 4 g per day, including any over-the-counter or prescription combination medications that contain acetaminophen. (Option 3) Metronidazole (Flagyl) is an anti-infective and pregnancy category B. Dark-colored urine is an expected side effect of metronidazole and not cause for concern.

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels(37%) 2. Human chorionic gonadotropin level(11%) 3. Serum folate level(49%) 4. White blood cell count(2%)

Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. (Option 2) Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. (Option 3) Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. (Option 4) A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection.

The nurse is caring for a client at 30 weeks gestation who is hospitalized for preeclampsia. After reviewing the client's chart and performing an initial assessment, the nurse notes several abnormal findings. Which finding should the nurse discuss with the health care provider immediately? 1. Dark red vaginal bleeding(56%) 2. Edema of the hands and face(21%) 3. Elevated liver enzymes(19%) 4. Urine output of 150 mL in 4 hours(2%)

Placental abruption is a potential complication of preeclampsia related to hypertension that can be life-threatening to the client or fetus. It causes premature detachment of the placenta from the uterine wall, resulting in bleeding from uterine blood vessels. Common manifestations include abdominal pain, dark red vaginal bleeding, a rigid uterus, abnormal fetal heart rate patterns, and uterine tachysystole. Once placental abruption occurs, fetal distress and maternal hypovolemia can develop quickly. Therefore, the nurse should report vaginal bleeding to the health care provider (HCP) immediately because emergency cesarean birth is very common if the client's or fetus' condition deteriorates (Option 1). (Option 2) Swelling is a common feature of preeclampsia that does not require emergency action, but the nurse should report facial or hand swelling to the HCP. (Option 3) Elevated liver enzymes are a severe feature of preeclampsia caused by impaired liver perfusion (end-organ damage) and are part of the diagnostic criteria for HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). HELLP syndrome requires prompt action because the definitive treatment is giving birth, but the client may be able to have labor induced. (Option 4) A urine output of approximately <30 mL/hr may be an early sign of kidney damage (end-organ damage) secondary to preeclampsia; the nurse should report decreasing urine output and strictly monitor intake and output.

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply. 1. Cervical softening on examination 2. Fetal heart tones detected by Doppler device 3. Positive serum human chorionic gonadotropin test 4. Report of fetal movement felt by client 5. Visualization of fetus by ultrasound

Positive (diagnostic) signs of pregnancy represent conclusive evidence of pregnancy and cannot be attributed to any other etiology. These signs include a discernible fetal heartbeat heard by Doppler device, ultrasound visualization of the fetus, and fetal movement palpated or observed by the health care provider (HCP) (Options 2 and 5). Presumptive (subjective) signs of pregnancy are self-reported by the client (eg, breast tenderness, nausea, amenorrhea). These signs may be related to other medical conditions and therefore cannot be considered diagnostic of pregnancy. Probable (objective) signs of pregnancy are observed by the HCP during assessment and examination (eg, cervical changes, positive pregnancy test). Combined with subjective signs, objective signs may be more indicative of pregnancy but may still have alternate causes. (Option 1) Cervical softening is an objective sign of pregnancy as it may also be caused by other conditions that result in pelvic congestion (eg, use of hormonal contraceptives, uterine tumors). (Option 3) A positive serum pregnancy test, which reports elevated levels of human chorionic gonadotropin, is considered an objective sign of pregnancy. Gestational trophoblastic disease can also cause positive results. (Option 4) The client's perception of fetal movement, known as quickening, is a presumptive sign of pregnancy.

A client indicates the desire to become pregnant. Which of the following are important preconception education topics for the nurse to provide? Select all that apply. 1. Aim for BMI of 18.5-24.9 kg/m2 2. Avoid alcohol consumption and tobacco products 3. Ensure daily intake of 400 mcg of folic acid 4. Obtain testing for rubella immunity 5. Schedule dental wellness appointment

Preconception counseling assesses for pregnancy risk factors and implements appropriate interventions to promote a healthy pregnancy. Some behaviors the client may begin independently include eating a nutritious diet; exercising; abstaining from alcohol, tobacco, and illicit drugs; and taking folic acid supplements. Obesity (BMI >30 kg/m2) during pregnancy is associated with an increased risk for fetal/maternal complications (eg, gestational diabetes, hypertension, cesarean birth). Achieving a normal BMI (18.5-24.9 kg/m2) is optimal (Option 1). No amount of alcohol is considered safe in pregnancy; complete abstinence from alcohol is recommended to avoid fetal alcohol syndrome. Smoking cessation is encouraged due to its association with fetal growth restriction; illicit drugs may also cause fetal harm (Option 2). Folic acid supplementation of at least 400 mcg per day for 3 months before pregnancy is recommended to reduce the incidence of neural tube defects (Option 3). Neural tube development begins around the third week following conception, before a woman may realize that she is pregnant. Finally, clients should visit their health care provider to discuss pregnancy's effect on certain health conditions (eg, asthma, diabetes) and check rubella immunity (Option 4). Rubella vaccination should be given if the client is nonimmune, and pregnancy should be avoided for at least 4 weeks after vaccination. Regular visits with a dentist can help prevent periodontal disease, which is associated with poor pregnancy outcomes (eg, preterm birth, low birth weight) (Option 5).

The nurse reviews laboratory test results for a pregnant client at 32 weeks gestation. What is the nurse's best action based on these results? Click on the exhibit button for additional information. 1. Complete the client assessment and documentation(56%) 2. Draw another sample for repeat complete blood count(7%) 3. Prepare for transfusion of packed red blood cells(9%) 4. Request a prescription for iron supplementation(26%)

Pregnant women experience a 40%-45% increase in total blood volume during pregnancy to meet the increased oxygen demand and nutritional needs of the growing fetus and maternal tissues. Because the increase in plasma volume is greater than the increase in red blood cells, a hemodiluted state called physiologic anemia of pregnancy occurs, and is reflected in lower hemoglobin and hematocrit values. It is also normal for the white blood cell count to increase during pregnancy; counts can be as high as 15,000/mm3 (15.0 x 109/L). These laboratory results are within the normal ranges for a pregnant client in the third trimester, and no intervention is required (Options 1 and 2). (Option 3) A blood transfusion should not be considered in pregnancy unless severe anemia (hemoglobin <7.0 g/dL [<70 g/L]) is suspected. (Option 4) Iron is frequently prescribed for pregnant women to prevent or treat iron deficiency anemia (hemoglobin ≤11 g/dL [110 g/L] and hematocrit ≤33% [0.33]). However, this pregnant client's laboratory results are within normal ranges, and iron supplementation is not necessary.

The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client, which factor places the client at an increased risk for preterm labor? 1. Age 25(4%) 2. Periodontal disease(65%) 3. Vegetarian diet(27%) 4. White ethnicity(2%)

Preterm birth is defined as birth before 37 weeks and 0 days gestation. Infection (eg, periodontal disease, urinary tract infection) is strongly associated with preterm labor, particularly when untreated (Option 2). Infection causes release of inflammatory mediators such as prostaglandins, which are uterotonic (ie, promote contractions) and contribute to cervical softening. Some risk factors for preterm birth may be modifiable with lifestyle changes and early treatment. Risk factors should be addressed at the initial and each subsequent prenatal visit to allow for early identification and management. Some risk factors for preterm birth include: History of spontaneous preterm birth in a previous pregnancy (single largest independent risk factor) Previous cervical surgery, such as a cone biopsy (weakens cervical support) Tobacco and/or illicit drug use (Option 1) Maternal ages <17 and >35 are associated with increased risk for preterm birth. Maternal age of 25 is not a risk factor. (Option 3) Maternal undernutrition can increase the risk for preterm birth and low infant birth weight. However, a balanced vegetarian diet with adequate pregnancy weight gain does not increase preterm birth risk. (Option 4) Non-Hispanic black women have the highest rates of preterm labor and birth. Non-Hispanic white ethnicity is not a risk factor for preterm birth.

The graduate nurse (GN) is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precepting nurse, which statement by the GN indicates an appropriate understanding? 1. "Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy."(47%) 2. "The client will require penicillin desensitization to receive appropriate treatment."(22%) 3. "The newborn can be treated after birth if antepartum treatment is contraindicated."(22%) 4. "Treatment is only effective if provided during the primary stage of syphilis."(8%)

Syphilis is a sexually transmitted infection that crosses the placenta and may have teratogenic effects on fetal development. All pregnant clients are screened for syphilis at the initial prenatal visit, and high-risk clients are screened again during the third trimester and labor. Maternal manifestations of syphilis may vary depending on the time of diagnosis. The only adequate prenatal treatment is IM penicillin injection (ie, benzathine penicillin G). Expected outcomes include resolution of maternal infection and prevention or treatment of fetal infection. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided (Option 2). (Option 1) Doxycycline, a tetracycline antibiotic, is a potential treatment alternative for nonpregnant clients with syphilis but is contraindicated in pregnancy because it can impair fetal bone mineralization and discolor permanent teeth. (Option 3) Syphilis that goes untreated can result in fetal or newborn death. Although some newborns require treatment after birth, complications (eg, skeletal abnormalities, anemia, preterm birth) related to congenital syphilis can be prevented with prenatal treatment. (Option 4) Many clients with primary syphilis have nonreactive serologic tests due to a delay in antibody development. However, IM penicillin therapy is appropriate for the treatment of primary, secondary, or latent syphilis.

The nurse assesses a client at term gestation who reports having contractions for the last 2 hours. The client states, "I'm not sure, but I think my water broke." The nurse performs a nitrazine pH test, which turns blue. When documenting the results of the test, which client statement is most concerning to the nurse? 1. "I did have sexual intercourse with my partner 1 hour before coming in today."(48%) 2. "I have noticed constant wetness in my panties since I thought my water broke."(21%) 3. "It is difficult for me to tell if my water broke or if I just peed on myself a little bit."(3%) 4. "With my last three pregnancies, my water never broke on its own."(26%)

Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. A yellow, olive, or green color suggests that amniotic membranes are intact. A bluish color suggests probable rupture of membranes (ROM). However, the presence of blood or semenmay result in a false positive, as serum and prostatic fluid are alkaline. A client history of recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen in the vagina (Option 1). (Option 2) Constant wetness of undergarments may indicate leaking amniotic fluid. This statement is not concerning and substantiates the positive nitrazine results and the client's history. (Option 3) Occasional involuntary urine leakage is common late in the third trimester as the gravid uterus presses on the bladder. Urine is generally acidic and should not inhibit nitrazine testing or cause a false positive. (Option 4) Many clients have never experienced spontaneous ROM, especially if previous labors were induced. This statement does not inhibit the nurse's ability to judge the accuracy of nitrazine results.

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1. The client had 1 birth at 37 wk 0 d gestation or beyond(66%) 2. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation(16%) 3. The client has 3 currently living children(8%) 4. The client is currently not pregnant(8%)

The GTPAL system is a shorthand system of documenting a client's obstetric history. This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation (Option 1). (Option 2) The client had 2 preterm births, indicated by the P2 portion of the GTPAL notation. (Option 3) The client has 2 currently living children, as indicated by the L2 portion of the GTPAL notation. If a child born full- or preterm is not living (due to stillbirth from 20 wk 0 d and beyond or infant/child death after birth), that birth and subsequent death is counted toward T or P (term or preterm) but is not notated under L (currently living children); T and P record total number of births without regard to current living status. This client has 2 currently living children (L2), which is 1 less than the client's total notation for term + preterm (T1 + P2 = 3). Therefore, the client has experienced the death of 1 child who had been born at 20 wk 0 d gestation or beyond. (Option 4) If a client is currently pregnant, the number of pregnancies (gravida) will be greater than the number of births (term, preterm, and abortions combined). This client is a G5, and T1 + P2 + A1 = 4. Therefore, the client is currently pregnant.

A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client? 1. 12 cm above the umbilicus(9%) 2. At the level of the umbilicus(7%) 3. Halfway between the symphysis pubis and the umbilicus(41%) 4. Just above the symphysis pubis(41%)

The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation (Option 4). At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid process around 36 weeks gestation. At 38-40 weeks, the fetus engages into the maternal pelvis and the fundal height drops. After 20 weeks gestation, the fundal height, measured in centimeters from the symphysis pubis to the top of the fundus, correlates closely to the weeks of gestation. (Options 1, 2, and 3) At 12 weeks gestation, the uterine fundus should be just above the symphysis pubis.

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for expected physical changes and discuss prevention of potential complications. Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on parity (Option 1). Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal (Option 3). Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation (Option 4). Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation. The nurse should also discuss routine screening/diagnostic tests performed during the second trimester. An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta (Option 2). Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test) (Option 5). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance.

The nurse is providing education to several first-trimester pregnant clients. Which client requires priority anticipatory teaching? 1. Client who gardens and eats homegrown vegetables(53%) 2. Client who has gained 4 lb (1.8 kg) from prepregnancy weight(22%) 3. Client who has noticed thin, milky white vaginal discharge(18%) 4. Client who practices yoga and swims in a pool 3 times a week(5%)

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus and potentially cause serious fetal harm (eg, stillbirth, malformations, blindness, mental disability). Pregnant clients should be advised to take precautions when gardening and thoroughly wash all produce to decrease exposure risk. (Option 2) Weight gain recommendations vary by prepregnancy BMI. A 1.1- to 4.4-lb (0.5- to 2.0-kg) weight gain in the first trimester and approximately 1 lb (0.5 kg) per week thereafter is normal and expected for women with a healthy BMI. (Option 3) Leukorrhea is a thin, milky white vaginal discharge that is normal during pregnancy and is due to increased levels of progesterone and estrogen. If discharge changes color, becomes malodorous, or causes itching/burning, further investigation is needed. (Option 4) Exercise, particularly low-impact activities such as walking, swimming, and yoga, is recommended during pregnancy. Contact sports or activities with a risk for falls (eg, soccer, downhill skiing) should be avoided to prevent abdominal injuries.

The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would bestprevent neural tube defects? 1. Calcium-rich snacks(7%) 2. Fortified cereals(68%) 3. Organ meats(16%) 4. Wild salmon(7%)

Women who are planning on becoming pregnant should consume 400-800 mcg of folic acid daily. Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables (Option 2). Inadequate maternal intake of folic acid during the critical first 8 weeks after conception (often before a woman knows she is pregnant) increases the risk of fetal neural tube defects (NTDs), which inhibit proper development of the brain and spinal cord. Common NTDs are spina bifida and anencephaly (lack of cerebral hemispheres and overlying skull). (Option 1) Adequate calcium intake is especially important during the last trimester for mineralization of fetal bones and teeth, but it does not prevent NTDs. (Option 3) Organ meats (eg, liver) may contain moderately high levels of folate but are consumed more for their high iron content, which can promote red blood cell formation and prevent maternal anemia. (Option 4) A prenatal diet rich in omega-3 fatty acids is important for fetal neurologic function and is linked to a lower risk of preterm birth. Dietary sources include wild salmon, anchovies, flaxseed, and walnuts.