Evolve - Maternity Uncomplicated Pregnancy

What recommendation should a nurse give to a client with fluid retention during pregnancy?

Elevate the lower extremities.

A nurse plans to evaluate a postpartum client's uterine fundus for involution. What should the nurse ask the client to do before this assessment?

Empty her bladder.

A multigravida of Asian descent weighs 104 lb, having gained 14 pounds during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do?

Encourage the family to bring in special foods preferred in their culture

A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of:

Slow-chest

A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The findings are interpreted as negative. What does the nurse conclude from this interpretation?

There will be weekly retesting because, at this time, the fetus has oxygen reserves.

After reading that nutrition during pregnancy is important for optimal growth and development of a baby, a pregnant woman asks the nurse what foods she should be eating. The nurse begins the teaching/learning process by:

Asking the client what she usually eats at each meal

A pregnant client uses a computer almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend?

"Try to walk around every few hours during the workday."

A client at 35 weeks' gestation asks a nurse why her breathing has become more difficult. How should the nurse respond?

"Your diaphragm has been displaced upward."

A nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:

7.5

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?

Cervical dilation

Identify the position of the fetus whose buttocks are in the fundus, whose fetal back is on the maternal right side between the midline, and lateral surface of the abdomen, and whose attitude is general flexion.

ROA

A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement?

"Nurse at least every 3 hours for at least 10 minutes on each breast."

A client arrives in the birthing room with the fetal caput emerging. What should the nurse say to the client during a contraction?

"Use the panting-breathing pattern."

A negative home pregnancy test may result if the woman performs the test:

10 days after intercourse took place

An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? (Select all that apply.)

2 "It would be good for you to come to labor and delivery to be evaluated today." 3 "Always call the health care provider if you're worried that your baby isn't moving enough." 4 "Let me teach you how to conduct a kick count, and then you can call me when you've done one."

What findings occur with supine hypotensive syndrome? (Select all that apply.)

2 Feeling of faintness 4 Increased venous pressure 6 Decreased systolic pressure

A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2013. Using Naegele's Rule, what date in June 2014 is the client's estimated date of birth (EDB)? Record your answer as a whole number. ________

21

What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement?

Apply cold packs to the breasts frequently.

While caring for a client during labor, the nurse remembers that the second stage of labor:

Ends at the time of birth

During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem?

Hypocalcemia; increase her intake of milk

The nurse is caring for a client who has just received epidural anesthesia. Which finding would be of most concern?

Hypotension

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored?

Hypotensive episodes

A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?

Neural tube defect

A nurse is teaching a client to care for her episiotomy after discharge. What priority instruction should the nurse include?

Perform perineal care after toileting until healing occurs.

What nursing action is the priority for a client in the second stage of labor?

Promote effective pushing by the client

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members?

Staphylococcus aureus

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What finding supports this conclusion?

Straw-colored, clear, and containing little white specks

Which position does the nurse teach the client to avoid when she experiences back pain during labor?

Supine position

A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. What should the nurse say?

Telling the mother, "I'm sorry, but I need to ask you to stay in the waiting area."

The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks' gestation. Which result after 20 minutes is suggestive of fetal reactivity?

Two accelerations of 15 beats/min lasting 15 seconds

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?

Uteroplacental insufficiency -Late decelerations are indicative of uteroplacental insufficiency and, left uncorrected, lead to fetal hypoxia, fetal myocardial depression, or both.

A client in labor is admitted to the birthing room. The exam reveals that the fetus is at -1 station. Where is the presenting part?

1 cm above the ischial spines

A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond?

"What activities does your job entail?"

A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do and, anyway, holding babies during feedings spoils them. What is the nurse's best response?

"You seem concerned about time. Let's talk about it."

A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. Which nursing action is best delegated to a licensed practical nurse/licensed vocational nurse (LPN/LVN) who also works on the unit?

Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort?

Applying pressure against her sacrum

A client at 35 weeks' gestation is experiencing contractions. Her cervix is dilated 2 cm. The nurse teaches the client that sexual activity, particularly intercourse, should be:

Avoided to limit the onset of labor

A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain?

By acting on opioid receptors to reduce pain -Nalbuphine (Nubain) is classified as an opioid analgesic and is effective in relieving pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce amnesia, act as an anesthetic, or induce sleep.

During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat?

Cheese and broccoli

A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?

Explaining why this is expected in early pregnancy

A primigravida client gave birth in a vaginal delivery 24 hours ago. Which findings would be considered normal?

Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present

A client who is at 10 weeks' gestation returns for her second prenatal visit. She asks why she has to urinate so often. The nurse tells her that urinary frequency in the first trimester is:

Influenced by the enlarging uterus, which is still within the pelvis

A nurse assesses the process of involution by measuring the location of the client's fundus during the postpartum period. Mark the location the fundus is expected to be 1 day after birth in a client whose bladder is not distended.

One day after birth, the fundus is expected to be at the level of the umbilicus. In the first 12 hours after birth the uterus is expected to be one fingerbreath above the umbilicus. It is then expected to descend by approximately one fingerbreath per day until it descends under the pubic bone, usually around day 10.

A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client?

Water intoxication

A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What should the nurse do first?

Inspect her perineal area

A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report:

Leakage of fluid from the vagina

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured?

Test the leaking fluid with nitrazine paper

A nurse notes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period?

It may indicate retention of urine with overflow.

The fetus of a client in labor is found to be at +1 station. What location does +1 station describe?

Just below the ischial spines

A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder:

May inhibit the progress of labor

A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? (Select all that apply.)

4 Black and pinto beans 5 Enriched bread and pasta

A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?

Discontinuing the test because the pattern is reassuring

After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond?

"I'll get you some warm blankets to help make the chill go away."

The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter?

"I'm not exactly sure how an epidural works."

While waiting for his 39-year-old wife to change clothes after an amniocentesis, the husband says to the nurse, "I sure hope that they don't find anything wrong because of my wife's age. I don't know how we'd deal with a child with Down syndrome. We already have two small children at home." What is the nurse's best response?

"It must be difficult, worrying about whether your baby will be disabled."

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? (Select all that apply.)

1 Smoker 2 Twin gestation

While caring for a client who gave birth 1day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreath below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats/min, and respirations are 16 breaths/min. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action?

Asking the client when she last changed the perineal pad -The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported without additional information.

What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques

A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At what point can the fetal heart be heard?

D

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time?

Massaging the client's fundus

A 24-year-old client who has been told that she is pregnant is at her first prenatal visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding her daily caloric intake include?

340 more calories during the second trimester

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with what?

Doppler ultrasound at 10 to 12 weeks

At 9 pm visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention?

Encouraging the sister to participate in care as much as the client wishes

A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy?

Fetal growth

In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent?

Fetal hypoxia

After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. The nurse notes that the fetus' head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder?

Gently guiding the head downward -After the newborn's head has rotated externally, the nurse gently guides the head downward for the birth of the anterior shoulder. Gradually flexing the head toward the mother's thigh, gently putting pressure on the head by pulling upward, and gradually extending the head above the mother's symphysis pubis are all contraindicated.

Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward:

Helping the client maintain control

A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder?

High level of chorionic gonadotropin -A high level of chorionic gonadotropin is frequently associated with severe vomiting during pregnancy and may result in hyperemesis gravidarum. A high level may also occur in the presence of a hydatidiform mole or multiple pregnancy.

A nurse performs Leopold's maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is:

LOA

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing action?

Placing the report in the client's record because this is an expected postpartum finding

At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client?

Planning nursing care activities that provide time for the client to rest and sleep

A nurse assesses a new mother who is breastfeeding. The client asks how to care for her nipples. What should the nurse recommend?

Spreading breast milk on the nipples after the feeding and allowing them to air dry

A couple who recently immigrated from Israel tell a nurse in the prenatal clinic that they are concerned about a genetic disease that is prevalent among Jewish people. Which genetic screening should the nurse expect the health care provider to recommend to determine the possibility of the couple's child's inheriting the disease?

Tay-Sachs disease -Tay-Sachs disease is a genetic disorder transmitted as an autosomal recessive trait that occurs primarily among Ashkenazi Jews. Cystic fibrosis, Phenylketonuria, and Turner syndrome do not have a higher prevalence in the Jewish population.

A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she is leaking breast milk. The best response is to tell her that:

This can be a normal occurrence during pregnancy

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction?

Turning the client on her side -Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. If signs and symptoms do not abate after the client is turned on her side, the health care provider should be notified. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia; it is part of the general nursing care during labor. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 minutes; if this monitoring is not being performed, the rate should be checked and recorded every 15 minutes.

Before a postpartum client is discharged, the nurse advises her about problems that should be reported and then asks her to recall these problems. Identification of which problem identified by the client indicates that the teaching has been effective?

Urgency, frequency, and burning on urination

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client?

Urine retention -Anesthesia blocks the sensory pathways; therefore the mother does not sense bladder distention and may be unable to void.

A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm. What should the nurse say while trying to calm the client?

"Medication may interfere with the baby's first breaths; keep breathing." -Analgesia crosses the placental barrier ; when birth is imminent, it can cause respiratory depression in the newborn.

A postpartum client who was receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor asks the nurse why it is not being discontinued now that the baby is born. The nurse responds:

"The oxytocin causes contraction of the uterine musculature." -Oxytocin (Pitocin) intensifies contractions of the uterus and promotes return of the uterus to its prepregnant state.

During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. What should the nurse advise the client about her position when she sleeps?

"Turn from side to side."

During a client's first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The client states that her mother told her that she should restrict her salt intake. What is the nurse's best response?

"Because you need salt to maintain body water Balance; it is not restricted. Just eat a well-balanced diet."

A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?

"During the eighth week of the pregnancy."

On her first prenatal visit a client says to the nurse, "I guess I'll be having an internal examination today." What is the nurse's best response?

"Have you ever had an internal examination done before?"

List the mechanisms of labor in the correct sequence:

1 Engagement 2 Descent 3 Flexion 4 Internal rotation 5 Extension 6 Restitution 7 External rotation 8 Expulsion

A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in the order in which they should be performed during pregnancy.

1 Sickle cell screening 2 α-Fetoprotein (AFP) testing for neural tube defects 3 Serum glucose for gestational diabetes 4 Fetal movement test 5 Group B Streptococcus culture

A pregnant woman at 6 week's gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client? (Select all that apply.)

1 Stop taking the supplement immediately. 2 Discuss the use of the supplement with the practitioner. 5 Discuss the use of any over-the-counter products with the practitioner.

A primigravida at 34 weeks' gestation tells the nurse that she is beginning to experience some lower back pain. What should the nurse recommend that the client do? (Select all that apply.)

1 Wear low-heeled shoes 4 Perform pelvic tilt exercises several times a day

A woman at 36 weeks' gestation is admitted to the hospital to receive a tocolytic medication in an attempt to stop labor. In addition, betamethasone (Celestone) is prescribed to enhance fetal lung maturity. The prescription reads: "Administer betamethasone 12 mg IM daily for 3 days." The betamethasone comes in a vial labeled "6 mg/mL." How many milliliters should the nurse administer each day? Record your answer using a whole number. ____ mL

2

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? (Select all that apply.)

2 Sitting 4 Lateral 5 Knee-chest

The nurse on the postpartum unit is providing postpartum care instructions to a 21-year-old Inuit woman who delivered her first baby yesterday without complications. Her husband, mother, and other family members have been with her since delivery. The mother speaks and understands very little English; however, her husband and sister speak some English. What is the best way to ensure that the client and her family understand what is being taught?

Asking the client and family members to repeat, in their own words, what they have been told

The clinic nurse is reviewing the dietary intake of a 16-year-old client who is 12 weeks pregnant. What is the nurse's most appropriate action in this circumstance?

Asking the client, "How many servings of dairy do you generally consume each day?

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located?

Below the ischial spines

A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions do what?

Come every 5 minutes for an hour

A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:

Compression by the enlarging uterus

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor?

Greenish-tinged amniotic fluid -Greenish amniotic fluid is common in a breech presentation because the contracting uterus exerts pressure on the fetus' lower colon, forcing the expulsion of meconium.

What prenatal teaching is applicable for a client who is between 13 and 24 weeks' gestation?

Growth of the fetus, personal hygiene, and nutritional guidance

A nurse in the prenatal clinic reviews second-trimester physiological changes in the hematological system before explaining them to a client. What change should the nurse identify?

Increased blood volume

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?

Meperidine (Demerol) -Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth.

During labor the nurse encourages the client to void periodically. The nurse knows that an over distended urinary bladder during labor can:

Predispose the client to uterine hemorrhage after birth

The nurse is caring for a client whose labor is to be induced. What is the nurse's responsibility when a client's labor is being stimulated with an oxytocin (Pitocin) infusion?

Stopping the infusion if contractions become hypertonic

A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?

Take a walk around the unit with her

The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating?

Taking-in

A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks' gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitored?

The machinery may be frightening to a laboring couple.

A client at 7 weeks' gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the:

Third month -Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin.

Immediately after the third stage of labor a nurse administers the prescribed oxytocin (Pitocin) infusion. Why is this medication administered?

To help the uterus contract

A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first?

Turn the oxytocin infusion off

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs?

When she is planning to become pregnant -The greatest danger of drug-induced malformations is in the first trimester of pregnancy, during the period of organogenesis; because a woman may not know that she is pregnant, she should be aware of this possibility before becoming pregnant.

The nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her regarding minimizing breast discomfort?

Apply covered ice packs to the breasts.

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference?

Cervix effaces and dilates during true labor.

A nurse is evaluating the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?

One or two fingerbreadths below the umbilicus -The fundus tends to stay at or slightly above the umbilicus for about 24 hours, then decrease in height by about one fingerbreadth per day. The location of the uterus during the first 24 hours postpartum is at or one fingerbreadth above the umbilicus

Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body. Record your answer using a whole number. ______

9

A woman who has just delivered an infant asks to take the placenta home with her and her new baby on discharge. What is the most appropriate response?

"I need to check the hospital protocol for our policy on that practice."

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn?

"The cardiac sphincter relaxes and allows acid to be regurgitated."

During a routine visit to the prenatal clinic a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should explain:

"The heart rate is usually rapid, and this one is in the expected range."

During a prenatal visit a client who is at 36 weeks' gestation states that she is having uncomfortable irregular contractions. How should the nurse respond?

"Walk around until they subside."

During a counseling discussion of nutrition, a nurse explains to a pregnant client that she will need additional calcium during pregnancy and that the best source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." What is the nurse's best reply?

"Your practitioner can prescribe calcium supplements."

A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.9 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response?

"Your weight is expected for someone at 23 weeks' gestation. Continue the pregnancy diet."

A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? (Select all that apply.)

4 Nitrazine paper turns blue on contact with the fluid. 5 Microscopic examination of the fluid reveals ferning/

A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression?

Abrupt decreases in fetal heart rate that are unrelated to the contractions

A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of pregnancy?

Accept that she is pregnant

While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats/min that lasts 15 seconds. How should the nurse document this event?

An acceleration

A client who expected to use the Lamaze technique throughout labor has an emergency cesarean birth. Three days later the client is found crying and tells the nurse that she is extremely disappointed because a cesarean birth was necessary. She asks the nurse why this happened to her. On what factor should the nurse base a response?

An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience.

After a client gives birth, what physiological occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

Appearance of a sudden gush of blood

What is the best nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs

A woman in labor with her third child is dilated 7 cm, and the fetal head is at station +1. The client's membranes rupture. What should the nurse do first?

Check the fetal heart rate while observing the color of the amniotic fluid

A client in active labor starts screaming, "The baby is coming! Do something!" What is the first nursing action?

Checking the perineal area for the presenting part

A client in active labor is admitted to the birthing room. A vaginal examination reveals that the cervix is dilated 6 to 7 cm. In light of this finding, the nurse expects that the:

Client's contractions will become longer and more frequent

An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned:

Occiput posterior

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?

G5 T1 P1 A2 L2 -The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions.

A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history?

G5 T2 P1 A1 L4

How should a nurse direct care for a client in the transition phase of the first stage of labor?

Helping the client maintain control

What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen?

Intrusion on movement

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains?

Multipara who has vaginally delivered three children -A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief.

A client at 42 weeks' gestation has a reactive nonstress test. The nurse determines that the client understands what she was taught about the results when she is overheard telling her husband that the test was:

Normal because of an increase in fetal heart rate (FHR) with fetal movement

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action?

Notifying the health care provider -Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous; the fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.

A nurse is teaching a primigravida about how she can identify the onset of labor. What clinical indicator of labor would necessitate the client to call her health care provider?

Rupture of membranes or contractions 5 minutes apart

A laboring client has asked the nurse help her to use a nonpharmacological strategy for pain management. Name the sensory simulation strategy.

Selecting a focal point and beginning breathing techniques

A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution?

The amount of lochia rubra is moderate.

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?

Uterine tetany

A nurse is preparing a pregnant client for an amniocentesis. What should nursing care include?

Encouraging her to void before the test

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to:

Estimate fetal age

A pregnant client arrives at the prenatal clinic, and the nurse obtains her obstetrical history. The client has two children at home, one born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Using the GTPAL system, record the client's obstetrical record.

G5 T1 P1 A2 L2 -G (gravida ) stands for the total number of pregnancies a client has had. Gravida 5 indicates that this is the client's fifth pregnancy. T (term) stands for the number of neonates born at the expected date of birth. The neonate born at 38 weeks' gestation was born at term. P (preterm) stands for the number of neonates born before the expected date of birth. The neonate born at 34 weeks' gestation was born preterm. A (abortion or miscarriage) stands for the birth of a fetus before 20 weeks' gestation. Both the miscarriage and elective abortion are considered abortions. L (living) stands for the number of living children at the time of assessment. The client has two living children.

A nurse is caring for a client in the first stage of labor and an external fetal heart monitor is in place. What do the tracings indicate?

Variable decelerations

A nurse concludes that a laboring couple has benefited from the Lamaze method of childbirth preparation when during the transition phase of labor they use the breathing pattern known as:

Pant-blow -Panting and blowing keeps the glottis open so the mother cannot hold her breath and bear down.

A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given?

Fetal lung maturity is accelerated. -A steroid such as betamethasone (Celestone) or dexamethasone (Decadron) administered to the mother crosses the placenta and promotes lung maturity in the fetus.

What is the primary outcome for client care in the third stage of labor?

Firmly contracted uterine fundus -The third stage of labor spans the time from the birth of the baby to the delivery of the placenta; a firmly contracted uterus is desired because it minimizes blood loss. Providing comfort is a desirable goal but is secondary to the life-threatening possibility of hemorrhage associated with a boggy uterus. Efficient fetal heart beat-to-beat variability is a concern in the first and second stages of labor; it is no longer applicable after the fetus is born. The maternal respiratory rate may vary above or below this range

A client is admitted in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify?

First

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action?

Having the client empty her bladder -A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. Therefore the bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not correct; the uterus will not remain contracted over a full bladder.

What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?

Moderate serosa

When performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position?

ROA -The fetus is in a right occiput anterior (ROA) position ; the prominence over the symphysis suggests a vertex and the fetal occiput and back are in the right anterior quadrant. Left occiput posterior (LOP) is ruled out because the occiput is not located in the left posterior quadrant; the occiput and back are on the mother's right side. Right sacral anterior (RAS) is ruled out because the fetus is in a vertex, not a breech, presentation. Left occipital anterior (LOA) is ruled out by the presence of irregular lumps on the left side, suggesting that the fetus's back is in the mother's right quadrant.

While caring for a client in labor, a nurse notes that during a contraction there is a 15-beat/min acceleration of the fetal heart rate above the baseline. What is the nurse's next action?

Record the fetal response to contractions and continue to monitor the heart rate

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place?

The most comfortable position may be assumed.

A client in her 37th week of gestation calls a nurse in the prenatal clinic and reports, "My ankles are swollen." What should the nurse recommend?

Elevating her legs more frequently during the day

The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?

Enlarging area of caput with each contraction -The client should be pushing with each contraction; with the head at +3 station, each push will bring more of the caput into view at the vaginal opening. It is too early for the perineum to be stretched to the point of tearing; if this should occur later, an episiotomy may be performed. Meconium is discoloring the amniotic fluid; it is an unexpected finding that may indicate that the fetus is at risk. There is a decreased, not an increased, amount of amniotic fluid at the end of labor.

A client whose membranes have ruptured is admitted to the birthing unit. Her cervix is dilated 3 cm and 50% effaced. The amniotic fluid is clear and the fetal heart rate is stable. What does the nurse anticipate?

Birth of the fetus within a day

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:

Doppler ultrasound at 10 to 12 weeks

A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has:

Drunk a glass of orange juice and timed 10 fetal movements -Drinking orange juice can increase fetal movement. Fetal kick count, either the number counted in 30 minutes or the time it takes for 10 kicks to occur, is the accepted method of assessing the fetus for the appropriate amount of movement.

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period?

Bradycardia with no change in respirations

After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones?

Below the umbilicus on the right side

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?

Breathe into her cupped hands -Dizziness and tingling of the hands are signs of respiratory alkalosis , probably the result of hyperventilating; breathing into cupped hands promotes the rebreathing of carbon dioxide.

A nurse is preparing to counsel a client whose two previous pregnancies were uneventful, ending in term vaginal births of healthy children. What should the nurse consider about multiparas with previous uneventful pregnancies before beginning prenatal counseling?

Each pregnancy is a unique experience that is stressful despite multiparity.

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain?

The anal sphincter muscle has been injured. -A third-degree laceration extends through the perineal muscles and continues through the anal sphincter muscle. Cutting of the perineal muscles constitutes a second-degree laceration. Trauma to the rectum constitutes a fourth-degree laceration. Damage to superficial muscles is a first-degree laceration.

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal:

Neural tube defects

A client is scheduled for amniocentesis. What should the nurse do before the procedure?

Remind the client to empty her bladder

A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" What information about adolescent growth and development does the nurse need to know before responding?

Body image is very important to adolescents, so pregnant teenagers are concerned about body size.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? (Select all that apply.)

1 Pain management with oral analgesics 3 Assessment of the site every 15 minutes 5 Application of an ice pack for 20-minute intervals

A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient?

Audible fetal heartbeat

One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next?

Continue periodic evaluations and record the findings

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?

Continuous infusion of heparin

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client?

Decreased blood pressure

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?

Different cultural groups favor different essential nutrients.

A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention?

Modeling appropriate behaviors that encourage infant bonding

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear?

Low-heeled shoes -Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area.

The four essential components of labor are powers, passageway, passenger, and psyche. Passageway refers to the bony pelvis. What type of pelvis is considered the most favorable for a vaginal delivery?

Gynecoid -A gynecoid pelvis is considered most favorable for a vaginal birth because the inlet allows the fetus room to pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus often gets stuck. The anthropoid pelvis is elongated, with a roomy anterior posterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.

A nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, what nursing intervention is required?

Maternal rubella vaccination

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. What condition does the nurse suspect that this result indicates?

Neural tube defect

During the examination of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?

First -The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is first stage of labor, from 8 cm of dilation to 10 cm of dilation

A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels?

Hemodilution

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Instruct her to void immediately before the test

A client is admitted in active labor. The nurse, performing Leopold maneuvers, determines that the fetus is in the left occiput anterior (LOA) position. Where should the nurse place the transducer of the electronic fetal monitor?

Left lower quadrant

A client is admitted to the birthing unit in active labor. Amniotomy is performed by the health care provider. What physiological change does the nurse expect to occur after the procedure?

Progressive dilation and effacement

On a routine prenatal visit the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time is:

Quickening

Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document?

ROA, 0 station

Which finding indicates the development of a complication resulting from the presence of bilateral cephalhematomas?

Skin color

A nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when:

The client reports that she feels the urge to move her bowels