CHAPTER 11: MATERNAL ADAPTATION DURING PREGNANCY
Which information provided by a client would be considered a presumptive sign of pregnancy? Reports of increased hunger Weight gain Breast tenderness Ballottement
Breast tenderness Explanation: Presumptive signs of pregnancy are things reported by the woman to the health care provider and occur early in pregnancy. Breast tenderness is a common sign reported by women in early pregnancy but is not a definitive sign. Reports of increased hunger and weight gain could be caused by any disorder or could be normal responses to eating cycles. Ballottement occurs late in the pregnancy and is a probable sign.
The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy? Fatigue Amenorrhea Positive home pregnancy test Nausea and vomiting
Positive home pregnancy test Explanation: A urine pregnancy test is considered a probable sign of pregnancy as the hCG may be from another source other than pregnancy. Fatigue, amenorrhea, and vomiting are presumptive or possible signs of pregnancy and can also have other causes.
A new mother asks the postpartum nurse if her baby is getting enough nourishment from breastfeeding within the first 24 hours following birth. The nurse would provide her what information? The mother needs to supplement breastfeedings with formula until her milk comes in. Breast milk comes in within 12 hours after delivery and nourishment should not be a problem. Most infants need minimal nourishment for the first 24 hours, so the mother should not be concerned. Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well.
Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well. Explanation: Colostrum is present prior to delivery and provides the infant with adequate nutrition for the first 3 days of life, at which time the mother's actual milk should come in. Formula is not recommended. Infants need nutrition shortly after birth to keep their blood glucose normal.
A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse? "It might be nothing. If it happens again call your provider who is on-call." "If the provider did an exam, it might be just normal vaginal secretions, so don't worry about it." "A one time discharge of bloody mucus in the toilet might have been your mucus plug." "Bloody mucus is a sign you are in labor. Please come to the hospital."
"A one time discharge of bloody mucus in the toilet might have been your mucus plug." Explanation: Bloody mucus can either be a mucus plug or bloody show. The one-time occurrence would be more likely to be the mucus plug. A bloody show would continue if her cervix was changing, but this usually does not occur until after contractions start. It is a sign that something is happening and should be reported to the health care provider. The bloody mucus is not a sign of labor, but it can be an early sign that labor is coming soon.
A client is about 16 weeks' pregnant and is concerned because she feels her "abdomen" contracting. She calls the primary care provider's office and speaks to the nurse. What is the nurse's most appropriate response to this client's concern? "What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy." "You need to go to the emergency room right away." "You need to come to the office to be examined." "You have nothing to be concerned about. I am sure you are not feeling contractions at this point in your pregnancy."
"What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy." Explanation: Braxton Hicks contractions are the painless, intermittent, "practice" contractions of pregnancy.
A urinalysis is done on a client in her third trimester. Which result would be considered abnormal? Trace of glucose 2+ Protein in urine Specific gravity of 1.010 Straw-like color
2+ Protein in urine Explanation: During pregnancy, there may be a slight amount of glucose found in the urine due to the fact that the kidney tubules are not able to absorb as much glucose as there were before pregnancy. However, there should be minimal protein in the urine. A specific gravity of 1.010 and a straw- like color are both normal findings.
A mother comes in with her 17-year-old daughter to find out why she has not had a menstrual cycle for a few months. Examination confirms the daughter is pregnant with a fundal height of approximately 24 cm. The nurse interprets this finding as indicating that the daughter is approximately how many weeks pregnant? 24 22 20 18
24 Explanation: By 20 weeks' gestation, the fundus of the uterus is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy. Therefore for this client, the additional 4 cm would be the equivalent of 4 additional weeks making the gestational age of 24 weeks.
A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client? Have you been sexually active in the past 2 months? Do you have a family history of breast cancer? Do you have vaginal itching? Are you taking oral contraceptives?
Have you been sexually active in the past 2 months? Explanation: The client is presenting with presumptive or subjective symptoms of pregnancy. Given her symptoms and age, asking about sexual activity is the most appropriate question. Whether she is taking an oral contraceptive will not assist in identifying the cause of her symptoms. If she has vaginal itching, the underlying cause of her symptoms needs to be identified before treatment can be prescribed. Asking about family history is part of a comprehensive health history, but is not the priority based on the client's presentation.
A pregnant mother may experience constipation and the increased pressure in the veins below the uterus can lead to development of what problem? Varicose veins Umbilical hernia Hemorrhoids Gastrointestinal reflux
Hemorrhoids Explanation: The displacement of the intestines and possible slowed motility of the intestines can lead to constipation in the pregnant woman. This, along with elevated venous pressure, can lead to development of hemorrhoids.
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet? Legumes Dairy Grains Meats
Meats Explanation: Meats are the best source of heme-rich iron and should be included in her diet if she is not following a vegetarian diet. Grains and legumes are non-heme iron sources. Dairy products will add various vitamins and calcium to the diet.
During a routine prenatal visit, a pregnant woman reports a white, thick, vaginal discharge. She denies any itching or irritation. Which action would the nurse take next? Notify the health care provider of a possible infection. Tell the woman that this is entirely normal. Advise the woman about the need to culture the discharge. Check the discharge for evidence of ruptured membranes.
Tell the woman that this is entirely normal. Explanation: Vaginal secretions increase during pregnancy and this is considered normal leukorrhea based on the woman's report that she is not experiencing any itching or irritation. There is no evidence indicating the need to notify the health care provider, check for rupture of membranes, or advise her about the need for a culture.
During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called? pseudo pregnancy pregnancy syndrome couvade syndrome cretinism
couvade syndrome Explanation: Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partner. This phenomenon is called couvade syndrome.
A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy? positive office pregnancy test fetal movement felt by examiner Hegar sign Chadwick sign
fetal movement felt by examiner Explanation: The positive signs of pregnancy are fetal image on a sonogram, hearing a fetal heart rate, and examiner feeling fetal movement. A pregnancy test has 95% accuracy; however, it may come back as a false positive. Hegar sign is a softening of the uterine isthmus. Chadwick sign may have other causes besides pregnancy.
A nurse who has been caring for a pregnant client understands that the client has pica and has been regularly consuming soil. For which condition should the nurse monitor the client? iron-deficiency anemia constipation tooth fracture inefficient protein metabolism
iron-deficiency anemia Explanation: Pica is characterized by a craving for substances that have no nutritional value. Consumption of these substances can be dangerous to the client and her developing fetus. The nurse should monitor the client for iron-deficiency anemia as a manifestation of the client's compulsion to consume soil. Consumption of ice due to pica is likely to lead to tooth fractures. The nurse should monitor for inefficient protein metabolism if the client has been consuming laundry starch as a result of pica. The nurse should monitor for constipation in the client if she has been consuming clay.
The nurse is teaching a pregnant woman about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as being released when the newborn sucks at the breast? oxytocin follicle-stimulating hormone antidiuretic hormone cortisol
oxytocin Explanation: Oxytocin is responsible for milk ejection during breastfeeding. Its secretion is stimulated by stimulation of the breasts via sucking or touching. Secretion of follicle-stimulating hormone is inhibited during pregnancy. The secretion of antidiuretic hormone has no effect on breastfeeding. Cortisol secretion regulates carbohydrate and protein metabolism and is helpful in times of stress.
A lactose intolerant client is concerned about getting enough calcium in her diet. Which gs could the nurse suggest she include in her diet to increase her calcium intake? Select all that apply. peanuts almonds broccoli molasses carrots
peanuts almonds broccoli molasses Explanation: The best source of calcium is milk and dairy products, but for women with lactose intolerance, adaptations are necessary. Additional sources of calcium may be necessary. These may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasses. In addition, encourage the woman to drink lactose-free dairy products or calcium-enriched orange juice or soy milk.
A new mother voices concerns about breastfeeding her infant. The nurse would explain to the mother the two hormones that control lactation and letdown are: follicle-stimulating hormone and thyroid hormone. prolactin and oxytocin. estrogen and progesterone luteinizing hormone and hCG
prolactin and oxytocin. Explanation: Prolactin and oxytocin are both important hormones in regulation of breastfeeding. Prolactin helps in producing the breast milk and oxytocin stimulates letdown during breastfeeding. The other hormones do not play a role in breastfeeding or milk production.
A nurse urges a pregnant client at the first prenatal office visit to begin taking iron supplements immediately. What is the rationale for this intervention? to avoid anemia to prevent megalohemoglobinemia to maintain proper blood glucose levels to reduce the risk for hypertension
to avoid anemia Explanation: The increase in the mother's circulatory red blood cell mass requires an additional 400 mg of iron per day or creates a total needed increase of about 800 mg. Iron deficiency can lead to anemia, which is a condition of lower-than-normal levels of red blood cells. Folic acid is taken to prevent megalohemoglobinemia (large, nonfunctioning red blood cells). Iron supplementation does not maintain proper blood glucose levels or reduce the risk for hypertension.
A client at 40 weeks' gestation informs the nurse that she is tired of being pregnant. What is the best response from the nurse? "Do you need to speak with someone about your feelings?" "That is a very normal feeling, especially at this point in pregnancy." "Most woman would have asked to be induced by this point. Is that what you want?" "Are you getting enough rest? If you don't take time for rest, that is why you might be tired."
"That is a very normal feeling, especially at this point in pregnancy." Explanation: During the third trimester, the client is preparing for parenthood and is often tired and ready for a break. The woman may feel large and unable to do any normal activities, and may feel ready to have the baby in her arms rather than in her uterus. This is not an abnormal statement, and the provider should not overreact. Deciding to induce labor is something that should be done in consultation with the health care provider and only when it is necessary for the health/safety of the mother or baby.
A woman's prepregnant weight is within the normal range. During her second trimester, the nurse would determine that the woman is gaining the appropriate amount of weight when her weight increases by which amount per week? 2/3 lb (0.30 kg) 1 lb (0.45 kg) 1.5 lb (0.68 kg) 2 lb (0.90 kg)
1 lb (0.45 kg) Explanation: The recommended weight gain pattern for a woman whose prepregnant weight is within the normal range would be 1 lb (0.45 kg) per week during the second and third trimesters. Underweight women should gain slightly more than 1 lb (0.45 kg) per week. Overweight women should gain about 2/3 lb (0.30 kg) per week.
The nurse is assessing a pregnant client at 20 weeks' gestation and obtains a hemoglobin level. Which result would be a cause for concern? 12.8 g/dl 11.9 g/dl 11.2 g/dl 10.6 g/dl
10.6 g/dl Explanation: The average hemoglobin level at term is 12.5 g/dl. The hemoglobin level is considered normal until it falls below 11 g/dl.
A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize? Cerebral arteries are growing congested with blood. The uterus requires more blood in a supine position. Blood is trapped in the vena cava in a supine position. Sympathetic nerve responses cause dyspnea when a woman lies supine.
Blood is trapped in the vena cava in a supine position. Explanation: Supine hypotension syndrome, or an interference with blood return to the heart, occurs when the weight of the fetus rests on the vena cava. Cerebral arteries should not be affected. Mean arterial pressure is high enough to maintain perfusion of the uterus in any orientation. The sympathetic nervous system will not be affected by the supine position.
The partner of a pregnant client in her first trimester asks the nurse about the client's behavior recently, stating that she is very moody, seems happy one moment and is crying the next and all she wants to talk about is herself. What response would correctly address these concerns? Her body is changing and she may be angry about it. Pregnant women often experience mood swings and self-centeredness but this is normal. Moodiness and irritability are not usual responses to pregnancy. What you are describing may be normal but we need to talk to her more in depth.
Pregnant women often experience mood swings and self-centeredness but this is normal. Explanation: During the first trimester of pregnancy, the woman often has mood swings, bouts of irritability and is hypersensitive. The partner needs to know that these are all normal behaviors for a pregnant woman.
A pregnant client at 24 weeks' gestation calls the clinic crying after a prenatal visit, where she had a pelvic exam. She states that she noticed blood on the tissue when she wiped after voiding. What initial statement by the nurse would explain this finding? The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. She may have a bleeding disorder so she needs to come back to the clinic for blood work. It is possible she is losing her mucus plug, which can cause bloody show. Some bleeding during pregnancy is not uncommon and this finding is expected.
The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. Explanation: Slight bleeding after a pelvic exam in a pregnant woman is common due to the vascularity of her cervix during pregnancy. Suggesting a bleeding disorder is frightening and not substantiated by the data. Bleeding is not a normal finding during pregnancy and losing the mucus plug occurs at the end of pregnancy, just prior to labor.
During an examination, a client at 32 weeks' gestation becomes dizzy, lightheaded, and pale while supine. What should the nurse do first? Listen to fetal heart tones. Take the client's blood pressure. Ask the client to breathe deeply. Turn the client on her left side.
Turn the client on her left side. Explanation: As the enlarging uterus increases pressure on the inferior vena cava, it compromises venous return, which can cause dizziness, light-headedness, and pallor when the client is supine. The nurse can relieve these symptoms by turning the client on her left side, which relieves pressure on the vena cava and restores venous return. Although they are valuable assessments, fetal heart tone and maternal blood pressure measurements do not correct the problem. Because deep breathing has no effect on venous return, it cannot relieve the client's symptoms.
A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to: encourage her to identify someone that she can talk to and share the pregnancy experience. tell her to move home so her family will be nearby to help her. remind her that she is still early in the pregnancy and she will feel better about it as the pregnancy progresses. offer to meet with the client on a regular basis to provide her someone to talk to about her concerns.
encourage her to identify someone that she can talk to and share the pregnancy experience. Explanation: A pregnant woman without social support needs to identify someone with whom she can share the experience of pregnancy because social support is a crucial part of adapting to parenthood. Telling her to move home and telling her that she will feel better as the pregnancy progresses do not address the issue of isolation. Also, moving home may not be a possibility for this woman. The nurse should maintain a professional relationship and not commit to a long-term relationship with a client.
What is a positive sign of pregnancy? positive pregnancy test fetal movement felt by examiner Hegar sign uterine contractions
fetal movement felt by examiner Explanation: The positive signs of pregnancy are fetal image on sonogram, hearing a fetal heart rate, and the examiner feeling fetal movement.
A client comes to the clinic and tells the nurse, "I think I might be pregnant." After completing the history and physical examination, the nurse obtains a blood specimen for pregnancy testing. When explaining this test to the client, which hormone will the nurse identify as being measured by this test? estrogen progesterone follicle-stimulating hormone human chorionic gonadotropin
human chorionic gonadotropin Explanation: The commonly used laboratory tests for pregnancy are based on the use of a venipuncture or a urine specimen to detect the presence of human chorionic gonadotropin (hCG), a hormone created by the chorionic villi of the placenta, in the urine or blood serum of the pregnant client. Because these tests are only accurate 95% to 98% of the time, positive results from these tests are considered probable rather than positive signs. The test does not evaluate the level of estrogen, progesterone, or follicle-stimulating hormone.
A client in her 39th week of gestation reports swelling in the legs after standing for long periods of time. The nurse recognizes that this factor increases the client's risk for which condition? hemorrhoids embolism venous thrombosis supine hypotension syndrome
venous thrombosis Explanation: During pregnancy, there is an increase in the client's blood components. These changes, coupled with venous stasis secondary to venous pooling, which occurs during late pregnancy after standing long periods of time (with the pressure exerted by the uterus on the large pelvic veins), contribute to slowed venous return, pooling, and dependent edema. These factors also increase the woman's risk for venous thrombosis. The symptoms experienced by the client do not indicate that she is at risk for hemorrhoids, embolism, or supine hypotension syndrome. Supine hypotension syndrome occurs when the uterus expands and exerts pressure on the inferior vena cava, which causes a reduction in blood flow to the heart. A client with supine hypotension syndrome experiences dizziness, clamminess, and a marked decrease in blood pressure.
