Maternal Child Chapter 5 and Chapter 6
When does a nurse caring for a patient with eclampsia determine that the risk for another seizure has subsided?
48 hours after postpartum
Which sign or symptom leads a nurse to suspect a patient has a tubal pregnancy?
A lower right or left abdominal pain radiating to the shoulder
A patient at 37 weeks' gestation is admitted to the birthing unit from the emergency department. She had arrived by ambulance after a motorcycle accident. Her vital signs are BP: 90/60; P:108; R:24. She is reporting sharp abdominal pain. What is the priority nursing intervention at this time?
Apply an electronic fetal monitor
What nursing intervention is specific to patients with cardiac problems who are in active labor?
Auscultating the lungs for crackles every 30 minutes
A nurse is preparing a teaching plan for a pregnant woman with a history of cholelithiasis. Which information about the ingestion of fatty foods will cause discomfort should the nurse include in the teaching plan?
Bile flow into the intestine is obstructed
Which clinical indicator should the nurse identify before scheduling a patient for an endoscopic retrograde cholangiopancreatography (ERCP)?
Bilirubin level
A patient is scheduled at a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she has severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. What complication does the nurse suspect?
Complete aburptio placnetae
A patient admitted with preeclampsia is receiving magnesium sulfate. Which assessment indicates that a therapeutic level of the medication has been reached?
Deep tendon reflexes of +2
What nursing intervention should be include when caring for a patient with placenta previa?
Documentation of the amount of bleeding
A client in the 18th week of pregnancy is scheduled for ultrasonography. What instruction should the nurse give the client?
Don't urinate for at least 3 hours before the test
A pregnant patient with class II heart disease is concerned that her pregnancy will be an added burden on her already compromised heart. A nurse explains during pregnancy the cardiac system is most compromised during what?
First 2 days after labor
What assessment finding of a pregnant patient should alert the nurse to notify the health care provider?
Fundal height at the umbilicus at 16 weeks' gestation
The nurse is reviewing the obstetric history of a patient who had an abruptio placentae. What prenatal condition does the nurse expect the patient to have had?
Gestational hypertension
A 42-year-old client has an 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 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply?
Open neural tube defects
A patient with the diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. What precaution should the nurse initiate?
Pad the side rails of the bed
A health care provider orders a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should alert the nurse to question the order?
Preterm labor Incompetent cervix Premature ruptures of membranes
Women who have become pregnant for the first time at a later reproductive age (35 years or older) are at risk of what complications?
Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester
Which woman should the nurse identify is at risk for developing a hypertensive disorder of pregnancy?
Primigravida who is obese
An 18-year-old pregnant woman in her first trimester is admitted with an acute onset of right lower quadrant pain at the McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the patient to determine whether the pain is secondary to appendicitis?
Rebound tenderness
A nurse is monitoring a patient with preeclampsia for the onset of eclampsia. What clinical findings indicates an impending seizure?
Rolling of the eyes to one side with a fixed stare
What does a nurse anticipate will be provided for newborn of a mother with long-standing diabetes?
Special high-risk care
After an incomplete abortion, a patient tells a nurse although her health care provider explained what an incomplete abortion was, she did not understand. What is the nurse's best response?
This is when the fetus is expelled but other parts of the pregnancy remain in uterus
A teenager at 32 weeks' gestation is hospitalized with preeclampsia. She is anorexic and appears depressed. Which comment indicates to the nurse that further exploration of client's emotional status is indicated?
I was really happy before I got pregnant
A client is scheduled for a nonstress test in the 37th week of gestation. A nurse explains the procedure. Which statement demonstrates that the client understands the teaching?
If the heart reacts well, my baby should do okay when I give birth
A patient arrives at the hospital at 38 weeks' gestational with profuse vaginal bleeding She states that it occurred suddenly without any contractions. Which condition may the patient be experiencing that require immediate notification of the health care provider?
Placenta previa
A nurse is monitoring a patient with severe preeclampsia who is receiving an infusion of magnesium sulfate. Assessment reveals a pulse rate of 55/minute, respirations of 12/minute, and a flushed face. What is the next nursing action?
Stop the infusion and start an infusion of dextrose and water
A 16-year-old adolescent visits the prenatal clinic because she has had three missed menstrual periods. Before her physical examination she says, " I don't know what the problem is, but I can't be pregnant". What is the nurse's most therapeutic response?
Why did you decide to come to the prenatal clinic?
A patient in the prenatal clinic is diagnosed with preeclampsia. What clinical findings support this diagnosis?
Blood pressure more than 140 mm Hg systolic
A patient at 37 weeks' gestation arrives at the emergency department stating that she has abdominal pain but no vaginal bleeding. The health care provider diagnoses aburptio placentae. The patient asks the nurse why it is so painful. What should the nurse consider is the initial cause of the abdominal pain before responding in language the patient will understand?
Concealed hemorrhage
A nurse is obtaining a health history from a patient with a diagnosis of a ruptured tubal pregnancy. At what point in the pregnancy does the nurse expect to state when the low abdominal pain and vaginal bleeding started?
About the sixth week of pregnancy
A nurse notifies the health care provider that a patient has been admitted to the high-risk unit in her 36th week of gestation. She is bleeding, has severe abdominal pain, and a rigid fundus, and is demonstrating signs of shock. For what intervention should the nurse prepare?
An immediate cesarean birth
A few hours after being admitted to the hospital with the diagnosis of inevitable abortion, a patient at 16 weeks' gestation begin to experience bearing-down sensations and suddenly expels the products of conception in the bed. What should the nurse do first?
Check the patient's fundus for firmness
Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identify that indicates the need for further instruction about complications associated with a multiple gestation?
Down syndrome
A nurse caring for a patient who had a spontaneous abortion. The patient asks why spontaneous abortion occur. The nurse responds that they are most commonly caused by what?
Embryonic defects
What is the initial responsibility of a nurse when teaching the pregnant adolescent?
Encouraging her to continue regularly scheduled prenatal care
A patient is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, +3 proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis?
Headache Abdominal pain Visual disturbances
A nurse is counseling a woman who was just diagnosed with multiple gestation. Why does the nurse consider this pregnancy high risk?
Perinatal morality is two to three time greater in multiple than in single births
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 amniotic fluid obtained through amniocentesis will reflect fetal lung maturity. Which test the nurse include in the discussion?
Phosphatidylglycerol (PG) test
A nurse in the birthing unit is caring for several clients. Which factor should the nurse anticipate will increase the risk for hypotonic uterine dystocia?
Twin gestation
A nurse suspects that there is cephalopelvic disproportion in a client who is having a difficult labor. For which test should the nurse prepare the client?
Ultrasound
A client at 9 weeks' gestation asks the nurse in the prenatal clinic if she can have her chorionic villi sampling (CVS) done at this visit. At what week gestation should the nurse respond is the best time for this test?
10 weeks and less than 12 weeks
What should the nurse anticipate about the insulin requirements of a woman with diabetes on her first postpartum day?
A sharp and sudden decrease
A nurse is caring for a woman with cholelithiasis and obstructive jaundice. When assessing this patient, the nurse should be alert for which common clinical indicators associated with these conditions?
Ecchymosis Yellow sclera Pain in upper right quadrant
A patient is discharged the same day after ambulatory surgery for a laparoscopic cholecystectomy. The nurse is providing discharge teaching about how many patients should wait to engage in certain activities. Place in order the activities from the first to the last in which the patient may engage in.
Getting out of bed in a chair -----> Performing light exercise -----> Shower ------> Driving a car ----> Lifting objects of more than 10 pounds
A nurse in the prenatal clinic is caring for a patient with a heart disease who is in the second trimester. What hemodynamic of pregnancy may affect the patient at this time?
Heart rate acceleration in the last half of pregnancy
A nurse caring for a patient who had a spontaneous abortion. For what complication should the nurse assess this patient?
Hemorrhage
A patient who had a severe abruptio placentae asks the nurse why there is so much bleeding. What should the nurse consider the cause of the heavy bleeding before responding in language the patient will understand?
Hypofibrinogenemia
A nurse anticipates that newborns of mothers with diabetes often have tremors, periods of apnea, cyanosis, and poor sucking ability. With what complication are these signs associated with?
Hypoglycemia
The nurse is counseling a patient with type 1 diabetes about medication changes as the pregnancy progresses. Which medication will be need in increased dosages during the second half of her pregnancy?
Insulin
A pregnant patient with a history of rheumatic heart disease since childhood is concerned about the birth of her baby and asks what to expect. What should a nurse explain about the birth?
Labor may be induced Birth may be vacuum extraction assisted Regional anesthesia may be administered
A patient is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicology should alert the nurse to intervene?
Lack of the knee-jerk reflex
A patient with class I heart disease is admitted to the birth suite in active labor. In what position should the nurse place the patient?
Left lateral with head elevated
A patient at 28 weeks' gestation has a sonogram. The results reveal a small-for-gestational-age (SGA) fetus and a low-lying placenta. For what complication should the nurse assess this patient during the last trimester of pregnancy?
Placenta previa
A couple who recently immigrated from Israel tells a nurse in the prenatal clinic that they are concerned about genetic disease that is prevalent among Jewish people. Which genetic test should the nurse recommend to determine the possibility of their child inheriting the disease?
Tay-Sachs disease
How should a nurse screen a newborn of a diabetic mother for hypoglycemia?
Test heel blood with a glucose-oxidase strip
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. How should the nurse respond?
The heart rate is usually rapid and is in expected range
A client visiting the prenatal clinic for the first time asks the nurse about the probability of having twins because her husband is one pair of fraternal twins. What is the appropriate response by the nurse?
There is no greater probability of having twins than in the general population
A client who is scheduled for a amniocentesis states, "I'm glad this test will be able to tell whether my baby is well or not." How should the nurse respond?
This test is useful in detecting potential defects due to chromosomal errors.
A patient tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her history reveals amenorrhea for the last two months and pregnancy confirmation after her first missed period. She is admitted to the high-risk unit because she may be having a spontaneous abortion. What type of abortion is suspected?
Threatened
A nurse is assessing a patient with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate?
Unusual uterine enlargement
A client pregnant with twins is told by the health care provider that she is at increased risk of postpartum hemorrhage. Later, the client asks the nurse why she is at increased risk for hemorrhage. What should the nurse consider in the cause of postpartum hemorrhage before responding in language the patient will understand?
Uterine atony
When caring for a woman who had a positive contraction stress test (CST), what complication does the nurse suspect?
Uteroplacental insufficiency
