HESI

A client's severe preeclampsia develops into eclampsia. After the seizure, the client has a temperature of 102° F (39° C). What does the nurse suspect as the cause of the temperature? 1 Excessive muscular activity 2 Development of a systemic infection 3 Dehydration caused by rapid fluid loss 4 Irregularity in the cerebral thermal center

4 Irregularity in the cerebral thermal center Increased electrical charges in the brain during a seizure may disturb the cerebral thermoregulation center in the hypothalamus. Excessive muscular activity usually causes perspiration, leading to a drop in body temperature. One increased reading is not a conclusive sign of infection. Rapid fluid loss does not occur during a seizure; clients with preeclampsia have fluid retention.

A client at 28 weeks' gestation has a sonogram. The results reveal a small-for-gestational age fetus and a low-lying placenta. For what complication should the nurse assess this client during the last trimester of pregnancy? 1 Preterm labor 2 Placenta previa 3 Premature separation of the placenta 4 Premature rupture of the membranes

2 Placenta previa Placenta previa is defined as an abnormally implanted placenta in the thin lower-uterine segment (i.e., low-lying, partially covering, or completely covering the cervical os). Preterm labor may occur at any time; it is not specific to a low-lying placenta. Premature separation of the placenta may occur with a normally implanted placenta. Premature rupture of the membranes may occur at any time, with or without a low-lying placenta.

A nurse is assessing several postpartum clients. Which conditions increase the risk for postpartum hemorrhage? Select all that apply. 1 Twin birth 2 Overdistended bladder 3 Hypertonic uterine dystocia 4 Retained placental fragments 5 Mild gestational hypertension

1 Twin birth 2 Overdistended bladder 4 Retained placental fragments Overdistention of the uterus may lead to delayed or inadequate uterine contractions. An overdistended bladder may inhibit uterine contractions. Retained placental fragments inhibit uterine contractions. Clients with ineffective uterine contractions are treated with rest and sedatives; although labor is prolonged, postpartum hemorrhage is not expected. Mild gestational hypertension does not interfere with uterine involution.

A 23-year-old primigravida is at her first prenatal appointment today. Ultrasound indicates that she is at 9 weeks' gestation. She asks when she can first expect to feel her baby move. The best response by the nurse is: 1 "You should be able to feel the baby move any day now." 2 "You should feel your first light movement of the baby around 24 weeks." 3 "Most women can first detect movement of their babies by 12 to 14 weeks." 4 "Many women are able to first feel light movement between 18 and 20 weeks."

4 "Many women are able to first feel light movement between 18 and 20 weeks." Fetal movement can be felt after 18 weeks and usually by 20 weeks in a primigravida. Fetal movement is normally not felt before 18 weeks' gestation, when the uterus has risen into the abdomen. Fetal movement should continue to be felt at 24 weeks' gestation but normally is felt 4 to 6 weeks before this time.

A 30-year-old gravida 1 para 0 experienced a miscarriage at 10 weeks' gestation. She is Rh negative. In light of this information, the nurse expects: 1 A prescription for one intramuscular microdose (50 mcg) of RhoGAM 2 A prescription for one intramuscular standard dose (300 mcg) of RhoGAM 3 A prescription for one subcutaneous standard dose (300 mcg) of RhoGAM 4 That RhoGAM will not be administered because the pregnancy ended in the first trimester and it is therefore not warranted

1 A prescription for one intramuscular microdose (50 mcg) of RhoGAM To prevent production of anti-Rh (D) antibodies in a Rh-negative woman who has been exposed to Rh-positive blood, a microdose of RhoGAM must be administered intramuscularly because the pregnancy ended in the first trimester. Had the pregnancy ended at 13 weeks of gestation or later, a standard dose of RhoGAM would be administered intramuscularly. RhoGAM is not administered subcutaneously.

A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? 1 In utero through the placenta 2 In the postpartum period through breast milk 3 During birth through contact with the maternal vagina 4 After the birth through a blood transfusion given to the mother

1 In utero through the placenta Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.

The nurse is caring for a patient that has just had an amniotomy performed by the health care provider. The fetal heart rate immediately decreased from 140 to 80 beats/min. What is the priority nursing action? 1 Inspecting the vagina 2 Administering oxygen 3 Increase the intravenous fluids 4 Placing the client in the knee-chest position

1 Inspecting the vagina Follow your nursing process and begin with assessment of the cause of the deceleration, which is likely to be a prolapsed cord due to the recent history of an amniotomy. Inspection is performed to identify the cause for the decreased fetal heart rate; a cord prolapse requires immediate removal of the presenting part from the cord. Oxygen may be administered later, but this is not the priority. Increasing the intravenous fluids is not the priority at this time. Placing the client in the knee-chest position is an intervention that can be implemented once it is determined that the umbilical cord is prolapsed. It relieves pressure on the cord, which increases the flow of oxygen and nutrients to the fetus.

A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply. 1 Maintaining intravenous fluid administration 2 Having oxygen available in case of hypotension 3 Checking the bladder for distention every 2 hours 4 Positioning the client supine for ease of monitoring 5 Monitoring fetal heart rate and labor progress per hospital protocol 6 Administering an oxytocin (Pitocin) infusion to maintain the labor pattern

1 Maintaining intravenous fluid administration 2 Having oxygen available in case of hypotension 3 Checking the bladder for distention every 2 hours 5 Monitoring fetal heart rate and labor progress per hospital protocol Hypotension is a common problem in the client receiving epidural analgesia. Intravenous fluids can help counter this problem and also provide a vehicle for emergency drug administration. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart tones and the progress of labor should be monitored. Oxygen should be available in case of hypotension occurs as a result of to the epidural block or as emergency care should the anesthetic agent migrate upward. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.

A client with preeclampsia is to receive a magnesium sulfate infusion, and the nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply. 1 Patellar reflex 2 Output of urine 3 Respiratory rate 4 Body temperature 5 Urine specific gravity

1 Patellar reflex 2 Output of urine 3 Respiratory rate A baseline measurement of the patellar reflex should be obtained because magnesium sulfate is a central nervous system depressant; an absence of patellar reflexes indicates magnesium sulfate toxicity. Magnesium sulfate is excreted by way of the kidneys; adequate urine output is necessary to prevent toxicity. Magnesium sulfate is a central nervous system depressant; a slowed respiratory rate is a sign of magnesium sulfate toxicity. Magnesium sulfate does not affect body temperature. The urine specific gravity test is not used before, during, or after magnesium sulfate therapy.

A client at 10 weeks' gestation complains of frequent urination. Before explaining this phenomenon to the client in language that she will understand, the nurse remembers that: 1 Glomerular filtration rate and renal plasma flow increase early in pregnancy. 2 The walls of the ureters undergo muscle tone relaxation during the first trimester. 3 Softening and compressibility of the lower uterine segment results in uterine anteflexion. 4 The uterus is taking on a globular shape as the uterine walls strengthen and become elastic.

3 Softening and compressibility of the lower uterine segment results in uterine anteflexion. Uterine anteflexion allows the uterine fundus to press on the urinary bladder, causing urinary frequency. Increased glomerular filtration rate and renal plasma flow changes do not produce urinary frequency; nor does muscle tone relaxation. The uterus does not become globular until the second trimester.

A client is admitted to the labor and delivery unit for labor augmentation with oxytocin (Pitocin). She is postterm at 40 weeks +3 days and is a gestational diabetic. The cervix is dilated 2 cm and 90% effaced. The health care provider performed an amniotomy to permit internal electronic fetal monitoring. The amniotic fluid is pale yellow and moderate in amount. Immediately after the amniotomy the nurse will assess the fetal heart rate for at least 1 full minute for signs of: 1 Infection 2 Uterine atony 3 Uterine cord prolapse 4 Maternal hypertension

3 Uterine cord prolapse The umbilical cord can slip down during after the amniotomy and be compressed between the fetal presenting part and the woman's pelvis. Cord compression is suspected if deep or prolonged variable decelerations occur during contractions or if persistent bradycardia is present after contractions. Uterine atony and maternal hypertension are not assessed with the use of electronic fetal monitoring. It is important to monitor the client for possible infection, but the risk is low immediately after amniotomy; it increases with the interval between membrane rupture and birth.

A client with severe preeclampsia in the high-risk unit is receiving an infusion of magnesium sulfate. If eclampsia were to occur, what action would the nurse take first? 1 Prevent injury. 2 Assess fetal heart tones. 3 Maintain an open airway. 4 Increase the infusion rate.

1 Prevent injury. The eclamptic client experiences seizures; protection from injury is always the priority with any seizure. With a rigid abdomen and occurrence of seizure activity, accurate assessment is improbable. Ensuring an open airway is done immediately after the seizure; injury may occur if force is applied to maintain the airway during the seizure. Intravenous effects are immediate, and increasing the dose may cause toxicity.

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant? 1 Increased Po2 2 Lowered HCO3 3 Decreased Pco2 4 Decreased blood pH

4 Decreased blood pH In addition to increased Pco2, hypoxia from inadequate oxygen/carbon dioxide exchange leads to anaerobic metabolism with an accumulation of acid by-products; both lower blood pH. Po2 is decreased because inadequate lung surface area is available for diffusion of gases. Acidosis, not alkalosis, is present; bicarbonate will be normal or increased in the body's attempt to compensate. Pco2 increases because inadequate lung surface area is available for the diffusion of gases.

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the care provider if the respiratory rate is slower than 20 breaths/min

1 Monitoring deep tendon reflexes 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside Maintaining a dark, quiet environment lessens stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. The medication level is monitored closely because toxicity may occur with levels over 8 mg/dL. Magnesium works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the health care provider. A respiratory rate slower than 10 breaths/min, not 20, must be reported to the health care provider.

A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented? 1 Precipitous vaginal delivery 2 Prolonged transitional phase 3 Primigravida primary delivery 4 Normal spontaneous vaginal delivery

1 Precipitous vaginal delivery A delivery that takes less than 3 hours is considered precipitous. A multipara usually progresses at the rate of 1.5 cm of dilation per hour and must progress to 10 cm for delivery. The second stage, birth, usually averages approximately 20 minutes. Although this was a vaginal delivery, it was faster than average. A prolonged transitional phase would indicate that progression from 8 to 10 cm took longer than expected and would require augmentation. Primigravida means "first pregnancy," so this cannot be not possible if the client is multiparous, having delivered before.

Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? 1 Uterine and kidney perfusion are maximized and compression of the major vessels is relieved by this position. 2 Intraabdominal pressure on the iliac veins is maximized and there is increased blood flow to the pelvic area. 3 Aortic compression is maximized, thereby decreasing uterine arterial pressure, and increasing uterine blood flow. 4 Hemoconcentration is maximized, thereby reducing blood volume and cardiac output, and increasing placental perfusion.

1 Uterine and kidney perfusion are maximized and compression of the major vessels is relieved by this position. In the left lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase. Maximizing intraabdominal pressure on the iliac veins will decrease, not increase, blood flow to the pelvic area. Maximizing aortic compression will decrease, not increase, uterine blood flow. Hemoconcentration occurs in the standing and sitting positions and uterine perfusion decreases.

What is the nurse's most critical assessment in a client with preeclampsia in the immediate postpartum period? 1 Vital sign 2 Emotional status 3 Signs of hemorrhage 4 Signs of hypovolemic shock

1 Vital sign Clients with preeclampsia are at risk for compromised cardiovascular and renal function and are still at risk for seizures in the immediate postpartum period; frequent assessment is vital in the first 48 hours. Although it is an integral part of care, evaluating the client's emotional status is not the priority. This client is at no higher risk for hemorrhage than any other postpartum client. Monitoring the client for hypovolemic shock is not the priority assessment.

At 36 weeks' gestation a client is scheduled for a contraction stress test (CST), and the nurse explains the procedure. Which statement indicates that the client understands the teaching? 1 "If this test causes my labor to begin early, it could affect the baby." 2 "If my baby's heart rate is OK, my labor won't be induced today." 3 "I hate having needles in my arm, but now I understand why it's necessary." 4 "I hope the baby doesn't get restless after the test; it can get uncomfortable."

2 "If my baby's heart rate is OK, my labor won't be induced today." The client's remark that labor will not be induced today if the fetal heart rate is acceptable indicates that the mother understands that the well-being of the infant will be established by the testing. A CST should not precipitate labor. The CST does not always require an intravenous infusion; nipple stimulation may be used to initiate uterine activity. The fetus is not affected by external monitoring.

A nurse is caring for a client who is having a precipitous labor. For what complication should the nurse make a focused nursing assessment when a rapid descent of the fetus is experienced? 1 Microcephaly 2 Fetal head trauma 3 Fracture of the maternal coccyx 4 Prolonged retention of the placenta

2 Fetal head trauma If there is bony or soft tissue resistance to the descent and birth, trauma to the fetal head may occur. Microcephaly is not associated with a birth event. A fractured coccyx is not associated with precipitous labor or birth. Although the placenta may be retained, this is not a specific complication of a precipitous birth.

A nurse is assessing several postpartum clients. Which problem does the nurse identify that will most likely predispose a client to postpartum hemorrhage? 1 Preeclampsia 2 Multifetal pregnancy 3 Prolonged first-stage labor 4 Cephalopelvic disproportion

2 Multifetal pregnancy More than one fetus overdistends the uterus, which may result in uterine atony. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.

At 32 weeks' gestation a client undergoes ultrasound, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term? 1 Sharp abdominal pain 2 Painless vaginal bleeding 3 Increased lower back pain 4 Early rupture of membranes

2 Painless vaginal bleeding Because the process of effacement occurs in the latter part of pregnancy, placental separation from the uterus may occur, causing painless bleeding. There is pain with premature separation of a normally implanted placenta (abruptio placentae). Lower back pain is not associated with placenta previa. Rupture of membranes usually does not occur before the placenta starts to separate.

A client in preterm labor at 35 weeks' gestation asks the nurse, "What determines whether my baby's lungs will be okay?" The nurse explains that a test of the amniotic fluid obtained through amniocentesis will reflect fetal lung maturity. Which test should the nurse include in the discussion? 1 Amniotic fluid index 2 Phosphatidylglycerol 3 α-Fetoprotein 4 Lecithin-sphingomyelin ratio

2 Phosphatidylglycerol Phosphatidylglycerol is a phospholipid that, if present in the amniotic fluid, indicates that the fetus's lungs are mature. The amniotic fluid index is a noninvasive measurement of the amount of amniotic fluid in the four quadrants of the uterus; it is assessed with the use of ultrasonography. The amount of α-fetoprotein in the amniotic fluid determines whether the fetus has a neural tube defect. Lecithin and sphingomyelin are surfactants, and by 36 weeks' gestation the lecithin/sphingomyelin (L/S) ratio should be approximately 2:1, indicating fetal lung maturity; however, the L/S ratio is not as accurate as the phosphatidylglycerol test.

A health care provider orders a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should prompt the nurse to question the order? Select all that apply. 1 Hypertension 2 Preterm labor 3 Drug addiction 4 Incompetent cervix 5 Premature rupture of membranes

2 Preterm labor 4 Incompetent cervix 5 Premature rupture of membranes The CST could trigger a preterm birth in a woman who is in preterm labor or has a history of preterm births. The CST could trigger a preterm birth in a woman who has had the Shirodkar procedure for an incompetent cervical os because it would exert pressure on the sutures and could cause them to rupture. The CST could trigger a preterm birth in a woman whose membranes have ruptured prematurely; the woman is at risk for a preterm birth already. The CST is indicated to assess the influence of hypertension on the placental circulation and determine the response of the compromised fetus to labor.

The nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention? 1 Giving a detailed explanation of what may have caused the stillbirth 2 Providing the parents the opportunity to say goodbye to their newborn 3 Explaining that autopsy is not recommended in the setting of a stillbirth 4 Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief

2 Providing the parents the opportunity to say goodbye to their newborn Parents should be given the opportunity to say goodbye to a stillborn baby. Because the parents may not think to ask to see the baby, the nurse should provide this opportunity. An autopsy may be performed when there is a stillbirth. The decision is left to the parents. The procedure can be very important in answering the question "Why?" if there is a chance that the cause of death can be determined. Giving a detailed explanation of possible causes of the stillbirth is nontherapeutic. Before the parents leave the hospital, arrangements for follow-up care should be made. Providing this information should be done immediately because it can help the parents begin the grieving process. Many hospitals have a team consisting of a social worker, chaplain, and nurse that is called when a stillbirth occurs.

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs? 1 Seizure activity is imminent. 2 Pulmonary edema has developed. 3 Bronchial constriction was precipitated by the stress of pregnancy. 4 Impaired diaphragmatic function was caused by the enlarged uterus.

2 Pulmonary edema has developed. Pulmonary edema is associated with severe preeclampsia; as vasospasms worsen, capillary endothelial damage results in capillary leakage into the alveoli. Crackles are not an indication of an impending seizure; signs of an impending seizure include hyperreflexia, developing or worsening clonus, severe headache, visual disturbances, and epigastric pain. Pregnancy does not precipitate bronchial constriction, although the hormones associated with pregnancy can cause nasal congestion. Impaired diaphragmatic function is a discomfort associated with pregnancy that may result in shortness of breath or dyspnea, not crackles.

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor? 1 Intense pain 2 Uterine tetany 3 Hypoglycemia 4 Umbilical cord prolapse

2 Uterine tetany Because oxytocin (Pitocin) promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise. Intense pain can be associated with strong uterine contractions; this is not a complication. Hypoglycemia is unrelated to uterine contractions. Umbilical cord prolapse is not likely to occur when induction of labor is initiated.

A client who is scheduled for an amniocentesis says, "I'm glad this test will be able to tell whether my baby is well." How should the nurse respond? 1 "Research has shown that this is an excellent test." 2 "A normal amniocentesis result is a reliable indicator of a healthy baby." 3 "This test is useful in detecting potential defects caused by chromosomal errors." 4 "An amniocentesis is a valuable tool for detecting congenital defects in the developing fetus."

3 "This test is useful in detecting potential defects caused by chromosomal errors." Amniocentesis has proved useful in detecting potential defects resulting from chromosomal and metabolic errors, such as Down syndrome, Tay-Sachs disease, hemophilia, thalassemia, and neural tube defects. Stating that research has shown that this is an excellent test is false reassurance and may stop further communication. Amniocentesis can identify many fetal defects, but even if none is detected, this does not guarantee a healthy newborn, because there are other factors that are required for a positive outcome. An amniocentesis does not detect congenital defects; the test can detect chromosomal anomalies, inherited errors of metabolism, and other disorders for which marker genes are known.

A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding? 1 Placenta previa 2 Tubal pregnancy 3 Abruptio placentae 4 Spontaneous abortion

3 Abruptio placentae Abruptio placentae is associated with cocaine use; it occurs in the third trimester. Placenta previa is seen in the third trimester but is not associated with cocaine use. A tubal pregnancy is identified in the first trimester. Spontaneous abortion occurs in the first two trimesters.

A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks' gestation. Which condition is a contraindication to the use of oxytocin (Pitocin) induction? 1 Chorioamnionitis 2 Postterm pregnancy 3 Active genital herpes infection 4 Hypertension associated with pregnancy

3 Active genital herpes infection Oxytocin is not administered when a woman has an active genital herpes infection. In this case, the baby would be delivered by means of cesarean section to help keep it from being infected during birth. Chorioamnionitis, hypertension associated with pregnancy, and postterm pregnancy are all indications for the use of oxytocin induction.

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? 1 Android 2 Anthropoid 3 Gynecoid 4 Platypelloid

3 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 is caring for a client who is receiving IV magnesium sulfate for preeclampsia. At 37 weeks' gestation she gives birth to an infant weighing 4 lb. What clinical finding in the newborn may indicate magnesium sulfate toxicity? 1 Pallor 2 Tremor 3 Hypotonia 4 Tachycardia

3 Hypotonia Hypotonia occurs with magnesium sulfate toxicity because of skeletal and smooth muscle relaxation. Pallor, tremor, and tachycardia are not signs of magnesium sulfate toxicity.

The nurse is caring for a client in active labor with a history of T5 spinal cord injury. Which of the following findings indicates to the nurse that the client is experiencing a complication of the labor process? 1 Increased pulse rate 2 Increased urine output 3 Increased blood pressure 4 Flaccidity in the lower extremities

3 Increased blood pressure A client with a spinal cord injury at T6 or higher is at risk for autonomic dysreflexia, marked by increased blood pressure and bradycardia. The nurse will need to carefully monitor this client throughout the labor process. An increased pulse rate may be a result of the adaptation of the labor process. Increased urine output would be expected because clients are well hydrated in labor; this does not indicate a complication. Flaccidity is an expected assessment finding for a client with this history.

A client in labor is admitted to the birthing unit 20 hours after her membranes rupture. What complication should the nurse anticipate when assessing the character of the client's amniotic fluid? 1 Cord prolapse 2 Placenta previa 3 Maternal sepsis 4 Abruptio placentae

3 Maternal sepsis Prolonged rupture of membranes more than 18 hours earlier increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection. Cord prolapse usually occurs shortly after the membranes rupture; it is unlikely that it will occur 20 hours after the membranes have ruptured. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Abruptio placentae is premature separation of a normally implanted placenta; it, too, is unrelated to ruptured membranes.

A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of five pounds since the previous checkup one week ago. The client has delivered and is receiving magnesium sulfate postpartum. The priority during the immediate four hours after delivery would be: 1 Monitoring blood pressure 2 Monitoring urinary output 3 Observing amount of lochia 4 Assessing breastfeeding technique

3 Observing amount of lochia Observing the amount of lochia is a priority during the four hours after delivery because of the risk of hemorrhage, which normally occurs during the fourth stage of labor, and the increased risk of low platelets because of blood clotting issues that accompany preeclampsia. Monitoring blood pressure is important to help assess for hemorrhage, but will be expected to decrease. Monitoring urinary output is important as the client diuresis and is expected to be above 30 cc/hr. The client would not be breastfeeding while receiving magnesium therapy.

A client is admitted to the birthing unit in active labor. Amniotomy is performed by the health care provider. What physiologic change does the nurse expect to occur after the procedure? 1 Diminished vaginal bleeding 2 Less discomfort with contractions 3 Progressive dilation and effacement 4 Increased maternal and fetal heart rates

3 Progressive dilation and effacement Amniotomy permits more effective pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Discomfort may increase because contractions usually become more intense after amniotomy. Amniotomy should not affect maternal or fetal heart rates.

A pregnant woman who is at term is admitted to the birthing unit in active labor. She is excited about the anticipated birth because she has three sons and the amniocentesis has indicated that she will have a girl. Which factor in the client's history alerts the nurse that the newborn will be at risk for a complication? 1 Her membranes ruptured 2 hours ago. 2 Her first child was found to have hemophilia. 3 She used NSAIDs for frequent sinus headaches. 4 She had a placenta previa in a previous pregnancy.

3 She used NSAIDs for frequent sinus headaches. Nonsteroidal antiinflammatory drugs (NSAIDs), as well as other over-the-counter drugs taken during pregnancy, may cause problems in the newborn during the neonatal period. NSAIDs are classified in pregnancy category C. Rupture of membranes is not a cause for concern; if the membranes ruptured more than 24 hours before birth, infection might be a concern. Hemophilia affects males; this fetus is known to be a female. A female may be a carrier but will not have hemophilia. A history of a placenta previa in an earlier pregnancy will not have implications for this newborn.

A client is found to have gestational hypertension in the 22nd week of gestation. What is a major complication of hypertensive disease associated with pregnancy that the nurse should anticipate? 1 Placenta previa 2 Polyhydramnios 3 Isoimmunization 4 Abruptio placentae

4 Abruptio placentae Vasospasms of placental vessels occur because of increased blood pressure, and the placenta may separate prematurely (abruptio placentae). Placenta previa is an abnormal placental implantation and is not related to hypertension. Polyhydramnios, an excessive amount of amniotic fluid, is not associated with hypertensive disorders of pregnancy. Isoimmunization in pregnancy is associated with Rh incompatibility, not hypertension.

The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L. What is the next nursing action? 1 Stopping the infusion 2 Assessing the client's deep tendon reflexes 3 Assessing the client's level of consciousness 4 Documenting the level in the client's electronic medical record

4 Documenting the level in the client's electronic medical record Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. Although the magnesium level is well above the normal range of 1.7 to 2.2 mg/dL, the therapeutic range for magnesium for the preeclamptic client is 4 to 7.5 mEq/L, or 5 to 8 mg/dL. The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear. These manifestations generally appear after the magnesium level is above 8 mg/dL; respiratory arrest is associated with a level above 10 mg/dL.

A nurse is caring for a 42-year-old client who is scheduled for an amniocentesis during the 15th week of gestation because of concerns about Down syndrome. What other fetal problem does an examination of the amniotic fluid reveal at this time? 1 Diabetes 2 Lung maturity 3 Cardiac anomalies 4 Errors of metabolism

4 Errors of metabolism Inherited errors of metabolism may be detected if marker genes for the disease, such as Tay-Sachs and thalassemia, are present. Fetal diabetes and cardiac disorders cannot be detected with amniocentesis. Fetal lung maturity cannot be determined until after 35 weeks' gestation.

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? 1 Lung maturity 2 Type 1 diabetes 3 Cardiac anomaly 4 Neural tube defect

4 Neural tube defect α-Fetoprotein in amniotic fluid is increased in the presence of a neural tube defect. Lung maturity cannot be determined until after 35 weeks' gestation. Neither diabetes nor cardiac disorders can be detected with the use of amniocentesis.

A nurse is admitting a client with the diagnosis of severe procidentia (prolapse of the uterus). What complication would the nurse anticipate finding during the assessment? 1 Edema 2 Fistulas 3 Exudate 4 Ulcerations

4 Ulcerations Ulcerations may occur when the vagina and uterus are displaced and exposed. Edema is not usually the problem. Fistulas are not associated with procidentia. Exudate is not present with procidentia.