Evolve Maternity and Women's Health Nursing - Pregnancy, At Risk

After a client's membranes rupture spontaneously, the nurse sees the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority

1.Call for assistance and don sterile gloves 2.Insert two fingers into the vagina and exert upward pressure against the fetal presenting part 3.Put a rolled towel under one hip and place in the modified Sims position 4.Administer oxygen to the mother and monitor fetal heart tones

A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing?

Abruptio placentae

A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse do first?

Insert an intravenous catheter

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?

Cesarean birth

A pregnant woman who was admitted to the high-risk maternity unit for severe hyperemesis gravidarum is receiving total parenteral nutrition (TPN). Intralipids are not being administered. For what potential complication should the nurse monitor the client?

Dehydration

A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin (Lovenox) for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse who is monitoring the client?

Dyspnea

What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia?

Maintaining a quiet, darkened environment

A client has a diagnosis of an unruptured tubal pregnancy. Which findings correlate with this diagnosis? (Select all that apply.)

Unilateral abdominal pain History of a sexually transmitted infection

A primigravida with type 1 diabetes is having her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur?

24th and 28th weeks of gestation

A nurse is caring for a postpartum client who had abruptio placentae. Which finding indicates that disseminated intravascular coagulation (DIC) is occurring?

Bleeding at the venipuncture site

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hours ago. Assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?

Obtaining maternal vital signs

While a client at 30 weeks' gestation is being examined in the prenatal clinic, the nurse identifies a respiratory rate of 26/min, blood pressure of 100/60, and diaphragmatic tenderness, and the client reports increased urinary output. Which finding indicates that the client may be experiencing a complication

Respiratory rate