Maternal Newborn - Antepartum

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching?

"Before bedtime is a good time to start counting the kicks." Rationale: Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. Alternatively, the client can count all fetal movements in a 12-hour period each day until at least 10 movements are counted. The kick count is performed at home and is noninvasive. The client does not need to come to the clinic for this diagnostic test. The kick count can be performed only once a day, but it should be counted for a total of 60 minutes if done once per day. When performing a kick count, the client does not have to wear loose clothing. The kicks come from inside the body, and clothing does not obstruct fetal movement or make counting difficult.

A nurse is admitting a client who is at 22 weeks of gestation for observation. The client informs the nurse that she has difficulty sleeping and requests to start taking herbal black cohosh. Which of the following information should the nurse include about black cohosh?

"Black cohosh affects hormones." Rationale: Black cohosh mimics estrogen. Black cohosh does affect hormones, relieving menopausal manifestations and helping disturbed sleeping patterns. However, black cohosh should not be taken during the first and second trimesters of pregnancy due to its estrogenic effects. Black cohosh is sometimes used to stimulate uterine contractions. Black cohosh and many other over-the-counter herbals supplements and medications should not be taken when pregnant due to possible adverse effects on the fetus. Encourage pregnant women to check with their obstetrician for a list of supplements and medications that can be taken while pregnant.

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?

"Do not become pregnant for at least 1 year." Rationale: Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition. Other considerations: Although the exact cause of molar pregnancies is unknown, it is not believed to be genetic. A baseline human chorionic gonadotropin (hCG) level should be obtained following the evacuation of the hydatidiform mole and then weekly until levels are normal for 3 consecutive weeks. Additional hCG levels should be obtained every 4 weeks for the next 6 to 12 months. Molar pregnancies tend to cause hypertension. However, this manifestation usually disappears once the abnormal products of conception are evacuated.

A nurse is providing teaching for a client who is at 12 weeks of gestation. Which of the following client statements indicates an understanding of the teaching?

"Drinking fluids in small amounts will help my morning sickness." Rationale: To avoid nausea and vomiting, the client should consume fluids in small amounts. The client should not limit fluid intake. The recommended water and liquid consumption during pregnancy is approximately 2.3 L/day (76 fluid ounces, or about 10 cups). Other considerations: - Although increased vaginal discharge is expected because of a decrease in vaginal pH, irritation, or pruritus, is not expected and can indicate vaginal infection. - Although fresh vegetables that are properly washed are safe to eat, the client should avoid eating uncooked seafood or meats. - The client should avoid soaking in hot tubs or saunas because hyperthermia is associated with neural tube defects

A nurse is providing preconception teaching to a client who has phenylketonuria (PKU). Which of the following statements by the client indicates an understanding of the teaching?

"I should avoid foods high in protein for at least 3 months prior to pregnancy." Rationale: The client should be instructed to avoid meat and beans and to eat more fruits and vegetables. A client who has PKU should decrease her dietary intake of protein for at least 3 months prior to conception and during pregnancy to prevent exposing the fetus to high phenylalanine levels, which can cause cognitive and neurological impairments. A client who has PKU will need to have her phenylalanine levels monitored one to two times per week throughout pregnancy. Phenylalanine is an amino acid that is converted into tyrosine once ingested. With phenylketonuria (PKU), the body is unable to form this conversion; thus, phenylalanine accumulates in the bloodstream and can attack the brain cells. PKU is an inherited disorder that can cause cognitive and neurological impairments. Treatment includes placing the client on a low-phenylalanine diet, which includes eating fruits and vegetables and avoiding high-protein foods like meat and beans.

A nurse is providing instruction to a client about common discomforts during pregnancy. Which of the following statements from the client indicates that further teaching is necessary?

"I should call my doctor if I develop a nosebleed or my gums start to bleed." Rationale: Increased estrogen levels during pregnancy can lead to an increased risk of capillary bleeding and connective tissue changes. The pregnant client may develop more frequent nosebleeds, gingivitis that leads to bleeding gums, and nasal congestion. These are not uncommon discomforts of pregnancy and do not warrant a call to the health care provider unless the bleeding is severe or cannot be stopped. Client interventions during pregnancy: "I should rest more often with my feet up, especially if I develop varicose veins in my legs." "It helps to lie down on my side when I start to feel dizzy and lightheaded." "I need to stop drinking so much fluid before I go to bed at night." The client should be taught to limit fluid intake at night if it is disrupting her sleep habits.

A client presents for a routine follow-up visit. Client is pregnant at 8 weeks gestation with a single fetus (8w0d). They have a history of moderate iron deficiency anemia. The client was sent for a hemoglobin and ferritin level, indicating iron deficiency anemia. The nurse calls the client to reinforce the provider's education regarding accurate understanding of the treatment plan.

"I should increase my dietary intake of whole-grain or enriched breads and cereals". "I should increase my dietary intake of dark, leafy greens." "I should take my iron supplement with orange juice every other day" Rationale: Dietary iron is highest in liver and other meats, whole grain or enriched breads and cereals, dried fruits, dark leafy green vegetables, and legumes. The absorption of iron supplements can be enhanced when administered concurrently with vitamin C, such as orange juice. Iron supplements should not be taken immediately after or with milk, coffee, or tea, as these beverages may limit iron absorption.

A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks the nurse to explain the purpose of using the vibration device. Which of the following responses should the nurse make?

"It awakens a sleeping fetus." Rationale: The acoustic vibration device is used during a nonstress test to awaken a sleeping fetus by using sound and vibrations. A baseline fetal heart rate is obtained prior to the test. If the fetus is nonreactive during the NST, the stimulator is activated for 3 seconds over the maternal abdomen over the fetal head. Usually within 3 min, the fetus will be reactive.

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide?

"This test will help determine if your baby is healthy." Rationale: NST is used as a prenatal fetal assessment. It tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress.

a pregnant woman can use a seatbelt?

"You can continue to wear your seat belt. Wear the lap belt low across your hips, under your pregnant abdomen." Rationale: Seat belts should be worn throughout pregnancy to promote safety for the mother and her unborn child. The correct position is low across the hips to prevent pressure on the pregnant abdomen. Pregnant women should not stop wearing their seat belts. The risk of entrapment of the mother is far less than the risk of trauma caused by expulsion from a vehicle. During pregnancy, the safest type of seat belt is a lap and shoulder belt combination. The lap belt should be placed below the client's abdomen, touching the thighs, and low on the hip bones. The seat belt should never be worn above or across the belly. The nurse should advise the client to always use the shoulder belt, which should fit snugly across the center of the shoulder and chest. The shoulder belt should never be placed under the arm or behind the back. When driving, the pregnant woman should make sure the abdomen is a safe distance away from the airbag. The breast bone should be at least 10 inches away from the dashboard or steering wheel.

A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching?

"You should expect to decrease your insulin dosage immediately after you deliver your baby." Rationale: The client will immediately lose insulin resistance upon the delivery of the placenta. Clients who have type 1 diabetes mellitus should expect to need only 50% to 60% of the pre-delivery dosage of insulin. Other considerations: Clients who are pregnant and have diabetes mellitus typically need lower insulin dosages during the first trimester of pregnancy due to hormonal changes that create an improved response to the insulin. Clients who are pregnant and have diabetes mellitus should expect to have increased insulin needs during the second and third trimesters of pregnancy due to placental hormones that cause insulin resistance. Clients who breastfeed typically require half of their pregnancy insulin dosages due to the carbohydrates used in the process of producing breast milk.

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide?

"You should slightly increase your exposure to sunlight." Rationale: Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching. It will resolve without extensive treatment and will go away after delivery.

A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statements should the nurse include in the teaching?

"You will probably first notice your baby moving when you are around 20 weeks gestation." Rationale: Fetal movement is typically noted by a pregnant client at 18 to 20 weeks gestation. Multiparous clients might notice the movement earlier. Increased urinary frequency and urgency is a common finding during the first and third trimester due to fetal pressure on the bladder. Urinary frequency and urgency during the second trimester should be reported to the provider. Recommended weight gain during pregnancy is typically 25 to 30 pounds. Clients should avoid a supine position during the latter half of pregnancy due to the risk of vena cava compression. Left lateral repositioning is preferred.

A nurse is caring for a client who is at 32 weeks of gestation during a routine prenatal visit. Which of the following client statements indicates a need for further evaluation? Select all that apply.

- "I felt my baby move six times in the past 2 hours". Expected fetal movement is at least 10 movements within a 2-hr period. A prompt evaluation is needed if fetal movement is less than 10 movements within 2 hr. - "I feel unusually weak and fatigued since we returned from our cruise last week". Traveling outside the country increases this client's risk of exposure to infections. - "I have this pain under my right rib, especially after eating". Right upper quadrant pain, especially after ingestion of high-fat foods, can indicate cholelithiasis.

A nurse is caring for a group of clients who are pregnant. Which of the following clients requires immediate follow-up? Select all that apply.

- A client who is at 20 weeks of gestation and reports headaches with blurred vision. Headaches with visual changes are manifestations associated with preeclampsia. - A client who is at 22 weeks of gestation and has greater than 2+ protein in a urine dipstick. A protein dipstick greater than or equal to 2+ (between 100 and 300 mg/dL) is unexpected and suggests an alteration in kidney function associated with hypertensive disorder in pregnancy. - A client who is at 18 weeks of gestation and reports vaginal bleeding. Vaginal bleeding is an unexpected finding that can indicate preterm labor. Other considerations: - The first sensation of fetal movement, or quickening, usually occurs between 16 to 20 weeks of gestation. - Clients who have a hemoglobin level of less than 11 g/dL and a hematocrit of less than 33% are considered to have anemia.

A client presents for initial prenatal care at 10 weeks of gestation. Which of the following findings should the nurse expect? Select all that apply.

- Breast enlargement and tenderness. In the first trimester of pregnancy, the breast enlarges, becomes tender, and the areola darkens due to increased melanocyte production caused by pregnancy hormones. - Resting heart rate increase by 10 to 30/min. Beginning in early pregnancy, the resting heart rate increases by 10 to 30/ min due to increased cardiac output. - Mild dyspnea while walking. Mild dyspnea during exertion and deep respirations beginning in the first or second trimester are expected due to rising levels of progesterone. - Nausea, especially in the morning. Nausea with or without vomiting, or "morning sickness," is expected in early pregnancy due to hormonal changes. other considerations: Although increased urinary frequency is expected beginning in pregnancy, dysuria is a manifestation of a urinary tract infection. The client's report of burning when voiding is an unexpected finding and warrants further evaluation.

Leopold maneuvers steps.

- Stand facing the client's head and place hands on either side of the client's upper uterus to palpate which fetal part is in the fundus is the first step. Leopold maneuvers are composed of four maneuvers. In the first maneuver, the nurse palpates the fetal part in the fundus. - Stand facing the client's head and use one hand to palpate for the fetal back and the other hand to identify the small parts of the fetus is the second step. In the second maneuver, the nurse continues palpating each side of the maternal abdomen to determine which side contains the curve of the fetal back and which contains the small parts, such as the feet, knees, and elbows. - Stand facing the client's head and use one hand to gently grasp the lower uterus to determine the presenting part and degree of descent is the third step. In the third maneuver, the nurse determines the location of the fetal presenting part, degree of fetal descent, and engagement by palpating above the symphysis pubis. - Stand facing the client's feet and use both hands to palpate the presenting part to determine the fetal position and presentation is the fourth step. With the fourth maneuver, the nurse confirms fetal presentation and engagement by applying gentle pressure at the fundus. At the same time, the index and thumb grasp the fetal part above the symphysis pubis.

A pregnant client is preparing to undergo a prenatal non-stress test. Which of the following is a reason for performing a non-stress test (NST)? (Select all that apply.) .

- Suspected Intrauterine Growth Restriction - Maternal diabetes - Multiple gestation Rationale: A non-stress test is a non-invasive fetal heart rate monitoring test that is performed after 28 weeks' gestation. The test measures changes in heart rate of the fetus in response to fetal movement, and how the fetus reacts to movements while in the womb. The NST is a non-invasive test typically performed after 28 weeks' gestation. It may be ordered for a variety of reasons, including problems with the pregnancy, such as suspected intrauterine growth restriction (IUGR), maternal diabetes, or when the mother is pregnant with more than one baby.

Danger Signs of the Third Trimester of Pregnancy:

- Vaginal bleeding - Leakage of fluid vaginally - Decreased fetal activity - Persistent uterine contractions before 37 weeks of gestation - Fever and chills - Dysuria - Pain in the abdomen - Epigastric pain - Persistent headache - Visual changes

The nurse is performing a prenatal assessment on a pregnant client in her First trimester. Vital signs are within normal limits. Which of the following signs does the nurse expect? (Select all that apply)

.Sore or tender breasts occur in the first trimester due to increased levels of estrogen and progesterone. Leukorrhea is expected in the first trimester because of the hyperplasia of the vaginal mucosa and increased production of mucus by the endocervical glands. It may also occur in the second trimester but is less common. In the third trimester leukorrhea will give way to the development of a mucus plug as the delivery date nears. Nasal stuffiness occurs in the first trimester due to elevated estrogen levels.

Which of the following pregnant women will most likely have a screening amniocentesis

A 36-year-old woman at 16 weeks' gestation Rationale: Amniocentesis is typically done between the 15th and 18th weeks of pregnancy. Amniocentesis screening is highly accurate for several birth defects such as Down's syndrome, sickle cell disease, cystic fibrosis, muscular dystrophy, and Tay-Sachs disease. Although there are some risks associated with this invasive procedure, it is recommended that pregnant women over the age of 35, those with an abnormal ultrasound, a prior delivery of a child with a birth defect, and/or a family history of birth defects. Amniocentesis is performed to screen the fetus for Down syndrome (trisomy 21); trisomy 13; trisomy 18; fragile X syndrome, neural tube defects, and inherited metabolic disorders. Indications for amniocentesis include diagnosis of fetal chromosomal anomalies after other tests (ultrasound or biophysical markers) have identified a significant likelihood that the fetus will be affected with a chromosomal problem. Amniocentesis is used to detect fetal lung maturity and evaluate alloimmunization. Amniocentesis can also be used to obtain samples to rule out chorioamnionitis and to deliver intra-amniotic dye in cases in which premature rupture of membranes is suspected.

A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives?

A client who is breastfeeding a 7-month-old infant Rationale: A client can begin using oral contraceptives 4 weeks after childbirth; therefore, this client is a candidate for oral contraceptive therapy. Smoking is a contraindication for oral contraceptive use because both smoking and oral contraceptive use increase the client's risk of myocardial infarction and stroke. Many medications interact negatively with oral contraceptives, including anticonvulsants, systemic antifungals, anti-HIV protease inhibitors and antituberculosis medications.

placental abruption.

A rigid abdomen is associated with a placental abruption. Severe abdominal pain is more often associated with a placental abruption. Cocaine use causes a disruption of the vascularity to the placental bed, leading to placental abruption

A nurse has been assigned to care for a pregnant client who has been diagnosed with HELLP syndrome. Which of the following nursing interventions is most important when caring for this client?

Administer magnesium sulfate as ordered Rationale: Magnesium sulfate is provided to reduce the risk of seizures, which occur with eclampsia. It may lower blood pressure slightly. HELLP syndrome is a severe form of preeclampsia. It most commonly occurs in the third trimester, but can develop earlier in the pregnancy or in the first 48 hours postpartum. Preeclampsia is characterized by new onset hypertension and proteinuria. Signs of preeclampsia or eclampsia, such as edema, hyperreflexia, or seizures may be present in HELLP syndrome. Blood is drawn and sent to the laboratory for CBC with platelet count, liver enzymes, and coagulation studies, including PT/PTT/INR, and fibrinogen. Close monitoring is critical. Delivery is sometimes postponed to allow the fetus to mature. The decision is based on the condition of the mother and fetus and the gestational age of the fetus. When delivery is delayed because of early gestational age, a course of corticosteroids is usually prescribed for the mother, to promote fetal lung maturation

A nurse is caring for a client who reports morning sickness at 7 weeks' gestation. Which of the following is the appropriate nursing response?

Advise the client to consume a snack high in carbohydrates and/or protein when she awakens. Rationale: The nurse should advise the client to consume a high-protein or high-carbohydrate snack on awakening and before bedtime; to eat several small meals high in protein or carbohydrates and low in fat throughout the day; to avoid excessive fluid intake early in the day or with meals but to consume ginger and flavored lollipops when nauseous. Women should be advised not to skip meals. The client should also consume foods that are high in vitamin B6 and/or iron. Cold or cool foods and beverages are recommended. Hot foods or spicy/fatty foods may worsen NVP. NVP is common in the first trimester of pregnancy, as a result of rising hormone levels. Dietary measures can be helpful to reduce symptoms, although some women may require antiemetic medication. Ginger and vitamin B6 supplements can be helpful. NVP usually resolves by the 14th week of pregnancy.

A 20-year-old client who delivered a full-term infant 24 hours ago by cesarean section has decided to sign herself and her baby out of the hospital. The nurse has been unable to contact the client's physician. Which of the following is the most appropriate action for the nurse to take?

Allow the client to take her infant home after completing all discharge instructions Rationale: The baby belongs to the mother and is under her guardianship. The mother may take the child with her when she leaves. Discharge against medical advice in postpartum women occurs most frequently among women who have had caesarean section delivery or otherwise complicated births. The risk of AMA departure is increased in vulnerable women with psychosocial and medical risk factors, so the nurse should provide discharge instructions and arrange early follow-up visits. The nurse should provide emotional support, identify the client's reason for early discharge, attempt to provide continuity of care after discharge, and consider additional steps, including referral to counseling or support services for vulnerable women.

A nurse is caring for a client who suspects that she is pregnant and has presumptive signs of pregnancy. Which of the following findings should the nurse expect the client to report? (Select all that apply.)

Amenorrhea Nausea and vomiting Quickening Rationale: Presumptive signs are findings the client notes and reports, such as Fatigue, Nausea and vomiting, Breast changes, Amenorrhea, Urinary frequency, Quickening. Other causes of presumptive signs: Illness, Oral contraceptives, Endocrine disorders, Infection, Peristalsis Probable signs are findings the provider can detect, such as Goodell, Hegar, and Chadwick signs. Ballottement, Positive pregnancy test. Oher causes of probable signs: Pelvic congestion, Tumor, Hydatiform mole. Positive signs are findings that can only be due to pregnancy, such as Ultrasound visualization of fetus, Auscultation of fetal heart tones, Palpation of fetal parts.

Signs of Early Pregnancy

Amenorrhea/missed periods Nausea/vomiting Breast enlargement/tenderness Increased frequency of urination Fatigue or lightheadedness Abdominal bloating/constipation Heartburn/reflux Nasal congestion Shortness of breath food carvings/pica Food aversions Mood swings or changes Palmar erythema New sign pigmentation or darkening of linea alba or areolas

Amniotic fluid Facts:

Amniotic fluid is formed in the membranous sac that surrounds the fetus and reaches a total volume at term of 500 to 2,500 mL. Amniotic fluid for analysis of fetal lung maturity is obtained by amniocentesis, a procedure for ultrasound-guided needle aspiration of fluid from the amniotic sac. When performed for assessment of lung maturity, it is performed between 26 and 35 weeks' gestation if fetal distress is suspected. Amniotic fluid can also be tested to identify genetic and neural tube defects, hemolytic diseases of the newborn, fetal infection, or fetal renal malfunction. These tests are usually performed between 14 and 16 weeks gestation.

A primigravid client at 35 weeks gestation is scheduled for a biophysical profile. After instructing the client about the test, which of the following, if stated by the client as one of the parameters of this test, indicates effective teaching?

Amniotic fluid volume Rationale: The biophysical profile typically measures five parameters to assess the fetus: fetal breathing, movement, and tone; amniotic volume; and fetal heart reactivity. The test uses a scale of 0 to 2 for each parameter with a maximum score of 10. A biophysical profile is a test performed in the third trimester to evaluate fetal health in cases where the pregnancy is considered high risk or when maternal or fetal signs and symptoms raise concerns. It consists of a fetal ultrasound and a nonstress test. The nonstress test monitors changes in fetal heart rate while the mother is at rest. The fetal ultrasound assess amniotic fluid volume, muscle tone, movement, and breathing.

The nurse is giving instructions to a pregnant client about BPP (biophysical profile). Which of the following are considered variables under the BPP?

Amniotic fluid volume Rationale: Using ultrasound, the amniotic fluid volume which is visualized as pockets of fluid around the fetus is evaluated to determine if the health status of the fetus is compromised. A pocket value lower than 1 cm in two perpendicular planes identifies a compromised status for the fetus. The obstetrician needs to be informed about this result.

A nurse is caring for a client who is at 30 weeks' gestation and scheduled for a biophysical profile. Which best describes the process of a biophysical profile?

An ultrasound is used to visualize characteristics of the fetus and observe for fetal responses to stimuli Rationale: A biophysical profile is a test used to assess the mother and the baby, particularly in a high-risk pregnancy. A biophysical profile combines an ultrasound with a non-stress test. It is performed during the third trimester to determine fetal health. The clinician performs an ultrasound to check the status of the baby while the mother pushes a button on a monitor when she feels the baby move. Movement, heart rate and "reactivity" of heart rate to movement are measured for 20-30 minutes. The ultrasound may take as long as an hour. Attributes measured in a biophysical profile include breathing, movement, muscle tone, heart rate, and amniotic fluid volume. Others tests: Non-stress test,: The clinician monitors the fetal heart rate and uterine contractions while the client pushes a button whenever she feels a fetal movement. Contraction stress test: Uterine contractions are stimulated while the fetus is monitored and the client presses a button whenever she feels a fetal movement Amniocentesis: A needle is inserted into the amniotic sac under ultrasound and a small amount of fluid is withdrawn for testing

The nurse is interviewing a pregnant client for her prenatal assessment. She is concerned about the EDD (estimated date of delivery) of her future baby. Her LMP (last menstrual period) was November 21st. Using Naegele's rule, when will be her EDD?

August 28 Rationale: Naegele's rule provides a way to calculate the due date for a pregnancy. The gestational age at childbirth is assumed to be 280 days. The expected date of delivery (EDD) is calculated by adding a year, subtracting three months, and adding seven days to the first day of the last menstrual period. If the client has her first day of LMP November 21, subtract 3 months resulting in August 21 and then adding 7 days finally produces August 28. EDD (estimated date of delivery) was formerly called EDC (expected date of confinement), a standard way of calculating for the due date of pregnancy. It is named after Franz Naegele who devised the rule. Though it is not accurate due to uncertainty about the exact determination of LMP, it remains popular among expectant mothers. The formula requires knowing the first day of the last menstrual period, then subtracting three months and adding 7 days afterwards. The result usually comes up 280 days (40 weeks) from the last menstrual period. Some of the more reliable methods for evaluating EDC are uterine size, date of quickening, presence of fetal heart rate, and ultrasound.

A primigravida client at 26 weeks gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following?

Backflow of stomach contents into the esophagus Rationale: Heartburn is caused when stomach contents enter the distal end of the esophagus, producing a burning sensation. The client should avoid spicy food, eat smaller portions and more frequent meals. Interventions used to relieve symptoms include diet and lifestyle modifications, antacids, antihistamines, and proton pump inhibitors. The increasing size of the baby may push some stomach acid upward, but it does not displace the stomach by the diaphragm. Decreased secretion of hydrochloric acid would not contribute to increased symptoms of heartburn.

A client at 12 weeks' gestation tells the nurse that she is a vegan and she eats "lots of rice." To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine rice with which of the following?

Beans Rationale: Protein intake is a concern for all who subscribe to vegetarian diets. Combining two incomplete proteins such as rice and beans to make a complete protein can improve the dietary intake of protein. Consumption of 75 to 100 grams of protein is recommended per day in pregnancy. Protein positively affects the growth of fetal tissue, including the brain. It is also necessary for the growth of breast and uterine tissue during pregnancy, and and in increasing blood volume. Pregnant women should also consume 400 mcg per day of synthetic folic acid from fortified foods (cereals and other grains), supplements, or both, in addition to consuming folate from foods from dietary sources; and 30 mg/day iron, beginning early in pregnancy Protein is found in a variety of foods, including: Beans and peas Dairy products like cheese, greek yogurt, and milk Eggs Grains and vegetables (these generally provide less protein than is found in other sources) Meats and poultry Nuts and seeds Seafood (fish and shellfish) Soy products

A nurse is providing care for a client who is at 28 weeks of gestation. The client has placenta previa and is actively bleeding. Which of the following medications should the nurse expect the provider to prescribe?

Betamethasone Rationale: Betamethasone is a common glucocorticoid given to a client who is pregnant and at risk for preterm delivery to promote fetal lung maturity. Because the client is actively bleeding, the nurse should identify that the client is at risk for preterm delivery. Other considerations: Oxytocin is used to stimulate uterine contractions. This medication is contraindicated for a client who has placenta previa. Methylergonovine is prescribed for a client who is experiencing postpartum hemorrhage. Placenta previa is a condition that occurs during pregnancy in which the placenta is implanted in the uterine wall close to the cervix. Clients who have placenta previa experience painless, bright red bleeding during their second or third trimester. Depending on the severity of the previa, the provider might monitor this closely and prescribe bedrest and no intercourse. Glucocorticoids, such as betamethasone, are given to clients who have placenta previa to enhance fetal lung maturity in the event of preterm delivery.

A nurse is providing care for a client who is in preterm labor at 30 weeks of gestation. Which of the following medications should the nurse expect the provider to prescribe to accelerate fetal lung maturity?

Betamethasone Rationale: Betamethasone is a glucocorticoid that is given to clients who are in preterm labor. It can be administered IM to increase fetal lung maturity through increased production of surfactant. Other considerations: Calcium gluconate is administered to treat magnesium sulfate toxicity. Indomethacin is an NSAID that is used to suppress preterm labor by blocking prostaglandin production to relax the uterine muscles. Oxytocin is an agent used to stimulate uterine contractions. Preterm labor or birth occurs when labor or delivery occurs prior to 37 weeks of gestation. Depending on the severity of the preterm labor manifestations, it is usually managed with restricted activity. Medications can be administered to stop uterine contractions, such as magnesium sulfate, nifedipine, or indomethacin.

A nurse is preparing to teach a group of clients who are pregnant about some of the common discomforts of pregnancy. Which of the following findings should the nurse include in the teaching? (Select all that apply).

Breast tenderness Excessive salivation Epistaxis (nosebleed) Rationale: Breast tenderness is caused by increased vascularity of the breasts and glands. Excessive salivation is caused by increased estrogen or nausea. Epistaxis is caused by increased estrogen. Many clients who are pregnant experience common discomforts due to the body adapting to pregnancy and hormonal changes. Some common discomforts during pregnancy include breast tenderness, urinary frequency, fatigue, nausea, vomiting, and excessive salivation. Clients should be informed of these discomforts and instructed about measures to relieve them. Other considerations: Dysuria is a complication that can occur during pregnancy and can be an indication of an infection. The nurse should instruct clients who are pregnant to report this finding to their provider. Right upper quadrant pain is a possible clinical finding of pregnancy-induced hypertension, especially hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. The nurse should instruct clients who are pregnant to report this finding to their provider.

A nurse is caring for a client who is receiving a magnesium sulfate IV infusion and exhibiting manifestations of magnesium toxicity. Which of the following medications should the nurse expect to administer?

Calcium gluconate Rationale: Calcium gluconate or calcium chloride can be administered intravenously to treat magnesium sulfate toxicity. It acts to increase the transmission of nerve impulses and contractions of cardiac, skeletal, and smooth muscle. Magnesium sulfate is administered intravenously to clients who are pregnant and have severe preeclampsia to prevent seizure activity. It is a central nervous system depressant that works to block neuromuscular transmission of acetylcholine. Magnesium is excreted through the kidneys. Therefore, an alteration in renal function, such as with preeclampsia, can lead to the development of magnesium toxicity. Manifestations of magnesium toxicity include absent deep tendon reflexes, respiratory depression, blurred vision, muscle weakness, a decreased level of consciousness, and cardiac arrest.

A nurse is caring for a client at 28 weeks' gestation who has a new prescription for dinoprostone (Cervidil). Which of the following is the most appropriate nursing intervention?

Call the doctor Rationale: The most appropriate nursing intervention by the nurse is to call the doctor for clarification when this drug is prescribed for a client at 28 weeks' gestation, since it is intended for clients at near term. It will harm both the mother and the developing fetus if not cancelled. Dinoprostone (Cervidil) is a form of prostaglandin E2 that is usually manufactured in gel form, used as a vaginal gel to "ripen" the cervix in pregnancy at or near term when induction of labor is indicated. It can be administered as a vaginal suppository for induction of midtrimester abortion, and management of missed abortion up to 28 weeks. Dinoprostone produces contractions similar to those occurring during labor at term by stimulating the myometrium. It initiates softening, effacement, and dilation of the cervix, known as "cervical ripening". Dinoprostone also stimulates GI smooth muscle. It is contraindicated for clients who can not deliver vaginally and for those who have had six or more pregnancies. It is also contraindicated if there is known allergy to prostaglandin.

An early sign of pregnancy is a bluish discoloration of the cervix from venous congestion. It can be observed as early as 8-10 weeks from the time of conception. It is known as:

Chadwick's sign Rationale: Chadwick's sign is a bluish discoloration of the cervix from venous congestion and can be observed by 8-10 weeks. Other signs: Goodell's sign occurs with softening of the cervix. Hegar's sign occurs when the lower portion of the uterus softens. The classic signs of pregnancy are missed menstrual cycle in a woman with menses of regular frequency, in association with nausea, vomiting, generalized malaise, and breast tenderness. On physical examination, signs include an enlarged uterus on bimanual examination, breast changes, and Hegar sign; approximately 6 wk)

A nurse is teaching a client who is antepartum about ways to prevent a TORCH infection. Which of the following information should the nurse include?

Clients should avoid consuming undercooked meat while pregnant. Rationale: Toxoplasmosis, which is a TORCH infection, can be contracted by consuming undercooked meat such as beef, lamb and pork. Clients who have a syphilis infection should receive treatment with penicillin as soon as possible to prevent transmission of the infection across the placenta to the fetus. Infants born whose mother received treatment within 4 weeks of delivery should be evaluated for signs of congenital syphilis. Most cases of herpes simplex virus (HSV) transmission occur during labor and birth due to viral shedding. This can occur whether or not the client presents with active lesions. The greatest risk of transmission occurs if the client experiences a primary HSV infection after 32 weeks of gestation. A small percentage of fetuses contract the infection across the placenta prior to birth. TORCH is an acronym which stands for toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex virus. These infections can all cross the placenta during pregnancy and cause adverse similar effects on the developing fetus. Clients who are pregnant and have a TORCH infection can exhibit influenza-like manifestations, such as tender lymph nodes, malaise, joint pain, fever, chills, and headache. Clients should receive education early in pregnancy about proper handwashing and hygiene, as well as instruction to avoid activities that increase the risk for developing TORCH infections, such as cleaning cat litter boxes and consuming raw or undercooked meats. The rubella vaccine should not be administered to clients who are pregnant, because it is a live virus vaccine which could cross the placenta and affect the fetus.

A nurse is caring for a client during her first prenatal visit and notes that she is lactose-intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?

Collard greens Rationale: Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. Collard greens also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects. Orange juice is high in vitamin C, but unless the orange juice is calcium-fortified, it is not a rich source of calcium.

A nurse is caring for a 33-year-old client who is at 32 weeks of gestation. The client has gestational diabetes mellitus and had a nonreactive nonstress test (NST). Which of the following provider prescriptions should the nurse expect?

Complete biophysical profile (BPP) Rationale: A nonreactive NST warrants further evaluation, such as a complete BPP. A BPP evaluates fetal breathing movements, fetal body movements, reflex/tone/flexion-extension movements, and amniotic fluid volume (AFV). This procedure assesses indicators of both acute hypoxia and chronic hypoxia.

A nurse is teaching a class to expectant mothers. Which of the following should the nurse advise the group to avoid in order to prevent toxoplasmosis?

Contact with cat feces Rationale: Toxoplasma gondii can be transmitted by exposure to infected cat feces or by ingesting undercooked contaminated meat. The parasite is found in warm-blooded animals If a pregnant woman has been infected with Toxoplasma before becoming pregnant, the unborn child is usually protected by maternal immunity. Experts suggest waiting for 6 months after a recent infection to become pregnant. Infected infants but are often asymptomatic at birth but can develop serious symptoms later in life, including blindness or mental disability. Infected newborns sometimes have eye or brain damage at birth. Pregnant women should avoid changing cat litter if possible. If no one else can change cat litter, the woman should wear disposable gloves and wash her hands with soap and water afterwards. The cat litter box should be changed daily. The parasite does not become infectious until 1 to 5 days after it is shed in a cat's feces. Household cats should be kept indoors and fed with commercially prepared foods.

T. N. is a 41-year-old male who has been brought into the clinic for severe nausea, vomiting, and abdominal pain. He recently started having leg cramps and backaches as well. His wife is in her 3rd trimester of pregnancy and suspects that he is having "sympathetic pregnancy" symptoms. Based on this information, which best describes the client's condition?

Couvade syndrome Rationale: Couvade syndrome, also called sympathetic pregnancy, develops in some men when their partners are expecting a baby. Couvade is a custom in some non-Western cultures.The father of the baby may experience such symptoms as nausea, abdominal pain, backache, or increased urinary frequency.

A nurse is caring for a client who is at 17 weeks of gestation and has a new diagnosis of molar pregnancy. Which of the following manifestations should the nurse expect?

Dark brown vaginal discharge Rationale: A molar pregnancy is a benign, excessive growth of the trophoblasts during early fetal development. This pregnancy is nonviable. It causes manifestations of a typical developing pregnancy. A client will initially appear to be pregnant but eventually starts experiencing clinical manifestations, such as dark red or brown vaginal bleeding, increased fundal height, nausea, and vomiting. A client who has a molar pregnancy has dark red or brown vaginal bleeding because there is no placenta to receive the maternal blood. The blood collects in the uterus and eventually manifests as abnormal bleeding. The client will have a fundal height measurement larger than anticipated for their gestational age. A molar pregnancy is diagnosed by ultrasound. Surgical intervention to remove the abnormal pregnancy contents, such as a dilation and curettage procedure, might be indicated if the pregnancy is not aborted spontaneously.

A nurse is providing nutritional teaching to a client who is at 8 weeks of gestation. Which food should the nurse recommend as a good source of calcium?

Dark green, leafy vegetables. Rationale: The nurse should recommend that the client consume dark green, leafy vegetables, such as kale, artichokes, and turnip greens. Vital Concept: Calcium is an essential mineral in the body that aids in fetal skeletal and teeth formation. It also is essential for maintaining maternal bone strength and tooth mineralization. Good sources of calcium include dairy or milk products and dark green, leafy vegetables, such as kale and turnip greens. It can also be fortified in products such as orange juice. It is recommended that a client consume 1,000 to 1,300 mg of calcium each day during pregnancy.

A nurse is caring for a client who is pregnant and scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply.)

Decreased fetal movement. Intrauterine growth restriction. Postmaturity. Rationale: A contraction stress test (CST) is used to evaluate the fetal response to stress and contractions. There are several indications to perform this test: abnormal nonstress test or biophysical profile, decreased fetal movements, post maturity, and intrauterine growth restrictions. The test is performed by using nipple stimulation or oxytocin. Using nipple stimulation, the client is instructed to massage her nipples to release natural oxytocin, which stimulates uterine contractions. Using oxytocin stimulation, the client is given oxytocin IV to stimulate uterine contractions. During the test, the nurse should monitor the fetal heart rate pattern for decelerations or accelerations. The desired result of the test is negative because a positive result indicates fetal distress. Placenta previa is a contraindication for a CST because of the possibility of the procedure stimulating labor. A client in preterm labor does not require a contraction stress test because this test stimulates uterine contractions

Which of the following situations constitutes an indication for a non-stress test? (Select all that apply.)

Decreasing fetal movement Twins or triplets Rationale: A non-stress test can be performed on a pregnant client as a non-invasive test to evaluate fetal response to in utero stimulation, such as fetal movement. A non-stress test is typically performed after 28 weeks' gestation and is used to assess fetal response in certain situations, such as during preterm labor or when twins or triplets are present. If there is decreasing fetal movement, the provider may also order a non-stress test to determine the baby's response. A nonstress test is the most widely used procedure for the evaluation of fetal well-being performed during the third trimester. The test monitors the response of the FHR to fetal movement noninvasively. A doppler transducer is used to monitor the FHR and a tocotransducer is used to monitor uterine contractions. They are externally attached to the client's abdomen to obtain tracing strips. The client may be asked to press a button attached to the monitor when she feels a fetal movement which is noted on the tracing. The procedure allows the nurse to assess the FHR in relationship to fetal movement.

During routine prenatal testing, it is determined that a pregnant client is not immune to rubella. Which of the following considerations must the nurse consider when preparing to administer the rubella vaccine?

Do not provide the vaccine to a pregnant client. The client cannot receive the vaccine until after childbirth Rationale: The vaccine is a live attenuated virus vaccine and is contraindicated in pregnant women. Although the client needs the vaccine for protection, it should not be given during pregnancy. The rubella vaccine is often administered the first postpartum day while the client is still in the hospital. Only one dose of the rubella vaccine is necessary to provide immunity. Some clients may develop pain or redness at the injection site with a rubella vaccine. Bleeding into the joints after the injection is not a side effect that usually occurs. A client who receives the rubella vaccine after giving birth can safely become pregnant again and does not need to wait six months. Rubella can be prevented with the MMR vaccine, which protects against three diseases: measles, mumps, and rubella. Children should receive two doses of the MMR vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age.

Which of the following is the most appropriate recommendation by the nurse who is caring for a client at 23 weeks' gestation with a complaint of significant heartburn?

Eat 6 small meals daily Rationale: During pregnancy, the stomach is displaced upward and compressed by the growing uterus. An increase in the hormone progesterone during pregnancy results in a slowing of the GI tract motility, delayed emptying time of the stomach, and relaxation of the esophageal sphincter, which can cause heartburn (pyrosis). The nurse should advise the client to eat frequent small meals in place of 3 larger meals each day. Other interventions to reduce heartburn include reduction of fluid intake with meals and elimination of dietary triggers like fatty or fried foods, carbonated drinks, spicy food, and caffeine or chocolate. The nurse should advise the client to stay in an upright position after meals to reduce reflux from the stomach into the esophagus. Clients should also be advised to elevate the head of the bed 4-6 inches. The upright position is recommended for 2-3 hours after meals to aid digestion and reduce heartburn. Alka-Seltzer or Sodium bicarbonate should be avoided during pregnancy when a better therapeutic alternative is available.

A nurse is caring for a client who has an intrauterine device (IUD). The client reports abrupt, sharp, lower abdominal pain and bright red vaginal bleeding. The nurse should identify that these are findings of which of the following conditions?

Ectopic pregnancy Rationale: An intrauterine device (IUD) is a device that is inserted into the uterus by a provider and releases hormones to prevent pregnancy by preventing fertilization or thickening the cervical mucus. One potential complication of using an IUD is an increased risk for ectopic pregnancy. An ectopic pregnancy is a pregnancy that is implanted outside of the uterus, such as in the fallopian tubes or abdominal cavity. A client who is experiencing an ectopic pregnancy presents with bright red bleeding and sharp abdominal pain. A client who is exhibiting these manifestations should be evaluated and treated immediately. Other considerations: A client who experienced a missed abortion reports brownish discharge and no pain. A client who has placenta previa will present with painless, bright red bleeding during the second or third trimester of pregnancy. A client who has a hydatidiform mole usually has dark brown vaginal bleeding during the second trimester that is not accompanied by abdominal pain.

A nurse in an emergency department is assessing a pregnant client who has cholecystitis. Which of the following findings should the nurse expect?

Epigastric pain Rationale: Cholecystitis is the term used to identify inflammation of the gall bladder. A pregnant client who has cholecystitis exhibits epigastric pain when a gallstone blocks the cystic duct. The client who is experiencing cholecystitis during pregnancy should decrease the manifestations of the disorder by modifying the diet, which can result in fewer episodes of pain, nausea, and vomiting. Nutritional recommendations for a pregnant client who has cholecystitis include: - Limit dietary fat intake to 40 to 50 g per day. - Select foods to receive most daily calories from carbohydrates. - Avoid fried foods. - Reduce protein intake to 10% to 12% of daily calories. - Prepare food without adding fat or oil. Other considerations: Dysuria and Suprapubic pain is a clinical manifestation of cystitis, which is a typically uncomplicated bladder infection during pregnancy. Anemia is a clinical manifestation of pyelonephritis, which is a serious renal infection and the leading cause of septic shock during pregnancy.

A nurse is assessing a client who is pregnant and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort?

Estrogen Rationale: Estrogen increases vascularity and connective tissue growth. Nasal stuffiness, a common discomfort in pregnancy, results from the increased vascularity of the mucus membranes within the nasal passages. other hormones: Relaxin causes loosening of the ligaments, making the pelvic joints more flexible to facilitate the birthing process. Progesterone has a relaxant effect on smooth muscle, which helps the uterus remain relaxed and maintain the pregnancy. The effects of this hormone also contribute to the occurrence of constipation and heartburn during pregnancy. Human chorionic somatomammotropin (HCS) HCS is produced by the placenta and stimulates the maternal metabolism to supply nutrients for fetal growth. This hormone is additionally responsible for lactation development of the maternal breasts.

A nurse is caring for a pregnant client whose last menstrual period was on February 11. By July 18, a physical assessment of the client should indicate that the top of the fundus is at which of the following locations?

Even with the umbilicus Rationale: At about the 22nd week of gestation, the top of the fundus is at the level of the umbilicus. The fundus is even with the umbilicus or halfway between the symphysis and umbilicus or the top of the fundus would be at about the umbilicus, Fundal height is defined as the distance from the pubic bone to the top of the uterus measured in centimeters. After 20 weeks of pregnancy, the fundal height measurement matches the number of weeks gestation, +/- 2 weeks. The fundal height measurement is not as accurate in women who are obese, carrying multiples, or with a history of fibroid tumors. A smaller or larger fundal height than expected or a fundal height that increases more or less quickly than expected could be due to intrauterine growth restriction, fetal macrosomia (large baby), oligohydramnios (reduced amniotic fluid), or polyhydramnios (increase in amniotic fluid.)

A healthcare provider orders a serum alpha-fetoprotein test for a pregnant client at 20 weeks' gestation. Which best describes the purpose of this test?

Excluding the presence of fetal neural tube defects. Rationale: A serum alpha-fetoprotein test detects the amount of a protein produced by the fetus during development. The test is typically performed between 15 and 22 weeks' gestation to rule out the presence of certain birth defects, including neural tube defects such as spina bifida. It may also be performed to detect the presence of genetic abnormalities such as Down syndrome or Turner syndrome. Alpha-fetoprotein is a fetal-specific globulin, synthesized by the fetal yolk sac, gastrointestinal tract, and liver. The function of alpha-fetoprotein is unknown, but it can be measured in maternal serum (MSAFP), amniotic fluid, and fetal plasma. Open neural tube defects (NTDs) are congenital anomalies that develop when a portion of the neural tube fails to close normally during the third and fourth weeks after conception. These anomalies can affect the vertebrae, spinal cord, cranium, and/or brain.

Findings in the third trimester

Expected findings: - Baseline FHR variability between 6 to 25 beats/min - Fetal position right occiput anterior - Fetal spine parallel to the long axis of the maternal spine Unexpected findings: - Amniotic membrane rupture before onset of labor, indicates PROM - Fetal heart rate decrease that begins after the peak of uterine contractions, indicates late decelerations. - A client whose cervix has remained dilated at 6 cm for more than 2 hr, indicates protracted or arrest of labor.

A nurse is teaching a client who is pregnant about the variables that are scored during a biophysical profile (BPP). Which of the following variables should the nurse include? (Select all that apply.)

Fetal breathing movement Fetal tone Amniotic fluid volume Rationale: A biophysical profile (BPP) is a noninvasive test that is performed via ultrasound in conjunction with a nonstress test to assess fetal well-being. The BPP monitor five variables: - Fetal breathing movement - Fetal movement - Fetal muscle tone, - Amniotic fluid volume - Fetal heart reactivity. Each variable can receive a score of 0 to 2. Fetal breathing is observed by ultrasound for 30 min, and the fetus should experience one episode of 30 seconds of maintained fetal breathing movements. Fetal movements are observed for 30 min, and the fetus must have three separate episodes of fetal limb or trunk movements to receive a score of 2. Fetal tone is observed for 30 min by ultrasound, and the fetus must extend and then flex the extremities or spine at least once to receive a score of 2. Amniotic fluid volume should measure more than 2 cm in a vertical diameter to receive a score of 2. Fetal heart reactivity is monitored during a nonstress test, and the fetus should exhibit two or more accelerations of fetal heart rate of 15/min, lasting 15 seconds each, following fetal movements in a 2-min period to receive a score of 2. A BPP score of 8 to 10 indicates good fetal well-being. A BPP score of 6 requires further evaluation, and a score of 4 indicates potential fetal distress.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?

Fetal gastrointestinal anomaly Rationale: Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios. Polyhydramnios will result in a fundal height greater than expected for gestational age. Polyhydramnios will result in an increase in weight gain

BPP Scoring Criteria and Variables BPP (biophysical profile) is an assessment tool to determine the status of the fetus in the uterus. There are 5 variables that comprise BPP: fetal breathing movements, fetal movements of body and limbs, fetal tone, reactive fetal heart rate with activity, and amniotic fluid volume. These variables are focused on the fetus and not the mother. A scoring system is provided where each variable is rated from 0 to 2. A total score from 8 to 10 is considered normal.

Fetal heart rate in response to the movements of the fetus.. Score 0. Nonreactive (no observation of 2 accelerations in 20 minutes) Score 2. Reactive (2 accelerations in 20 minutes, each lasting 15 seconds and peaking at 15 beats above the baseline heart rate) Amniotic fluid index (AFI) or amniotic fluid volume Score 0. AFI less than 5 cm or no single and pocket greater than 2 cm. Score 2. AFI greater than 5 cm or at least one pocket of amniotic fluid greater than 2 cm. Fetal muscle tone Score 0. Fetus is observed during ultrasound for muscle tone. Absent means decreased extension or flexion. Score 2. Fetus is observed during ultrasound for one episode of extension with flexion of fetal limb or trunk. Fetal movements of body and limbs Score 0. Fetus is observed during ultrasound for 30 min and has less than 3 trunk/limb movements. Score 2.Fetus is observed during ultrasound for 30 minutes and has at least 3 trunk/limb movements. Fetal breathing movements Score 0. Fetus is observed for 30 minutes for breathing movements. Absent means no breathing movements by the fetus or less than 30 seconds of maintained breathing during the 30 min. Score 2.Fetus is observed for 30 minutes for one or more occurrence of fetal breathing movements of 30 seconds in duration.

A nurse in a clinic is teaching a client who is planning to become pregnant about the effects of folic acid deficiency. Which of the following complications should the nurse include?

Fetal neural tube defects Rationale: Folic acid supplementation prior to and during pregnancy reduces the risk of neural tube defects in the fetus. Folic acid has a direct effect on the closure of the neural tube. Deficiency of folic acid can result in defects such as spina bifida, encephalocele, and anencephaly. Dietary sources of folic acid, or folate include leafy green vegetables, grains, liver, peanuts, and fortified products such as cereals and whole-grain breads. Neural tube defects affect the development of the fetus in the first trimester and can result in severe nervous system damage, brain malformation, and spina bifida. The recommended daily intake of folic acid for clients who are planning to become pregnant is 400 mcg daily.

A nurse is providing education to a client who has just had her first prenatal visit. Which of the following should be included as part of routine education about self-care measures for a pregnant client?

Get a flu shot during the autumn or winter to protect against influenza infection Rationale: Getting a flu shot during high-risk months is safe for most pregnant women, and will protect against influenza infection that could lead to severe illness during pregnancy. Other considerations: Most women need approximately 300 extra calories a day while pregnant, but this amount varies depending on a woman's weight and health prior to becoming pregnant. Because iron supports hemoglobin synthesis, a woman needs to eat more foods with iron while pregnant to make sure that both she and her baby are getting enough oxygen. Physical activity is beneficial during pregnancy. Activities such as yoga and swimming are low-impact options that can increase strength and reduce many of the discomforts of pregnancy.

Folic acid is important before and during pregnancy because folic acid:

Helps to prevent neural tube defects in the newborn Rationale: Folic acid is critical for the prevention of neural tube defects in the newborn. To be most effective, the mother should begin taking folic acid about six months BEFORE becoming pregnant and then throughout the pregnancy. Folate is regulated by insulin and glucagon. Folate (folic acid) is a B vitamin. Folate and vitamin B12 are necessary for the formation of normal red blood cells and the synthesis of DNA (deoxyribonucleic acid) Folate is also necessary for normal development of a fetus's nervous system. Folate deficiency in a pregnant woman increases the risk of defects of the spinal cord or brain in the fetus.

A nurse is caring for a G2P1 client at 26 weeks' gestation. Which of the following findings should the nurse prioritize to report to the healthcare provider?

Hemoglobin of 9.2 g/dL Rationale: Iron deficiency anemia is a common cause of anemia during pregnancy, as a result of a diet low in iron and low iron stores. Most women who are pregnant are advised to take a multivitamin with iron to meet the increased iron needs of fetal development and to maintain adequate maternal stores of iron. Additional supplementation may be required if anemia persists despite taking a multivitamin with iron. Hemoglobin levels <11 g/dL in the first or third trimester and <10.5 g/dL in the second trimester are considered abnormal, so this is the priority option. Other considerations: An acidic pH is normal during pregnancy. It inhibits the growth of bacteria and reduces the risk of infection. Leukocytosis of up to 15,000 cells/mm^3 is normal in pregnancy. A 1-hour glucose screen consists of measurement of blood glucose 1 hour after consumption of a 50-gram oral glucose load. It is normal if it is <130 mg/dL.

The nurse is caring for a pregnant client at 32 weeks gestation. The client underwent a 3-hour oral glucose tolerance test (OGTT) at 26 weeks and was diagnosed with gestational diabetes. The client is currently being managed with self-monitoring of blood glucose (SMBG) and dietary modifications. The client visits the nurse to assess their blood glucose control over the last week, complete the nurse's statement.

I am thrilled that you consistently check your blood glucose when you wake up and one hour after eating your meals. Based on your results from last week, I would like you to - start exercising regularly and decrease your carbohydrate intake- this week to see how that affects your numbers.

A nurse is caring for a client who is pregnant and has a TORCH infection. Which findings should the nurse expect? (Select all that apply).

Joint pain Rash Decreased appetite Rationale: Clients who are pregnant and have a TORCH infection will exhibit influenza-like manifestations, such as tender lymph nodes, malaise, fatigue, joint pain, fever, chills, and headache; also rash, decreased appetite, and ocular findings. TORCH stands for toxoplasmosis; "other" (syphilis, parvovirus, and varicella zoster); rubella; cytomegalovirus (CMV); and herpes simplex virus (HSV). Urinary frequency is not a clinical finding associated with a TORCH infection. The effects of these infections include significant congenital anomalies and even death. Clients should be taught early in pregnancy about proper handwashing and hygiene. Women who are pregnant should avoid activities that increase the risk for developing TORCH infections, such as cleaning cat litter boxes and consuming raw or undercooked meats.

A nurse is preparing to perform a non-stress test. Which position would the nurse recommend that the client be placed in?

Lateral position Rationale: The client is placed in a lateral position to avoid vena cava compression. Pregnant clients should not be placed in a supine position for prolonged periods as this may result in compression of the large vessels (vena cava) due to the gravity/weight of the full uterus on those vessels. This compression can cause decreased blood flow.

A multigravida client is scheduled for a diagnostic test to measure fetal lung maturity. The nurse is providing instructions for the client. Which of the following diagnostic tests is appropriate for this client?

Lecithin and sphingomyelin ratio Rationale Fetal lung maturity is an indicator of the viability of a neonate or newborn child. Mature lungs enable the newborn to adapt to extrauterine life effectively. Surfactant is a substance composed of phospholipids that lowers the tension of alveoli when a newborn exhales. Lecithin and sphingomyelin are components of the surfactant. It is best analyzed from an amniotic fluid sample. At 35 weeks gestation, the ratio of these components is 2:1. This ratio indicates that the risk for respiratory distress syndrome is low.

A nurse is caring for a client in preterm labor who is scheduled to undergo amniocentesis to evaluate fetal well-being and lung maturity. Which of the following tests does the nurse understand will be used to assess fetal lung maturity?

Lecithin/sphingomyelin (L/S) ratio test Rationale: A test of the L/S (lecithin/sphingomyelin) ratio is determined by amniocentesis. The test is used to determine fetal lung maturity. A sample of the amniotic fluid is analyzed to identify presence of surfactant. Surfactant is needed by the fetal lungs to keep the alveoli from collapsing and to promote gas exchange. Other tests: The AFP (alpha-fetoprotein) test is used to assess for fetal neural tube defects or chromosome disorders and is performed at around 15 weeks of gestation. The Kleihauer-Betke test measure the amount of fetal hemoglobin transferred to the maternal circulation, usually after trauma. It is performed in an Rh negative mother to assess the amount of RhoGAM. A chorionic villus test requires a sample of the placenta to check for chromosomal abnormalities of the fetus.

An adult female client presents for a routine follow-up visit. Client is pregnant at 28 weeks gestation with a single fetus and has a history of moderate iron deficiency anemia. Which subjective information supports an improvement in their iron deficiency anemia throughout their pregnancy.

Lightheadedness resolved. Reports fatigue improved. No longer craving ice. Denies fatigue and lightheadedness. Rationale: .Symptoms of iron deficiency anemia may include fatigue, lightheadedness, weakness, and pallor. Many clients will report PICA cravings to eat ice with significant iron deficiency. The improvement in the client's lightheadedness and craving for ice are likely related to the improvement in iron deficiency anemia. The improvement in the client's fatigue could be related to the improvement in iron deficiency anemia. This may also be related to a general improvement in fatigue seen during the second trimester of pregnancy.

A nurse is caring for a client who is at 32 weeks' gestation on her first prenatal visit. The client reports varicella zoster infection during the sixteenth week of pregnancy. Which of the following is the fetus at risk for? (Select all that apply.)

Limb hypoplasia Congenital cataracts Rationale: If intrauterine exposure occurs during the first 28 weeks of gestation, the fetus is at risk of congenital varicella syndrome. Multiple abnormalities associated with congenital varicella syndrome include central nervous system abnormalities, limb hypoplasia, chorioretinitis, congenital cataracts, microcephaly, limb dysplasia, auditory nerve palsy, cutaneous scarring, and delays in motor and cognitive development. Varicella zoster virus causes chickenpox and herpes zoster (shingles). In pregnant women, antibodies produced as a result of immunization or previous infection are transferred to the fetus via the placenta. If the mother does not have immunity, exposure may result in an infection that is transmitted to the fetus. Neonatal varicella is associated with maternal varicella infection during the perinatal period 5 days before delivery to 2 days after birth. Infants at risk of neonatal varicella should receive IVIG or varicella zoster immune globulin at birth. Disseminated varicella infection is associated with neonatal varicella. The neonate should receive prophylactic varicella immunoglobulin at birth if the mother has been exposed to varicella during the period from 5 days before birth to two days after delivery. Symptoms range from mild rash to disseminated infection. There is a high risk of serious complications, including pneumonia.

A client with bipolar disorder has been taking lithium for 3 years. She and her partner are attempting to conceive a child. How should she be advised concerning her medication?

Lithium poses few risks to the fetus in the second and third trimester. Rationale: Lithium carbonate is an anti-manic medication used for prophylaxis and acute control of manic episodes in bipolar disorder. It crosses the placenta and poses many developmental risks to the fetus in the first trimester, although there are few risks of birth defects in the second and third trimester. During the second and third trimesters of pregnancy, the benefits may outweigh the risks in a client who has bipolar disorder.

A healthcare provider is caring for a woman with abruptio placentae (a placental abruption). Which of the following are risk factors for this condition? (Select all that apply).

Maternal hypertension Cocaine use Cigarette smoking Advanced maternal age Rationale: Maternal hypertension, Cocaine, and Cigarette smoking are risk factors for abruptio placentae due to the constriction of the uterine blood vessels, which can cause the placenta to separate. Increased maternal age is a risk factor for abruptio placentae. Depending on the source, mothers > age 35-40 are at an increased risk. Vital concept: Abruptio placentae occurs due to abnormal placental implantation. The exact cause of abruptio placentae is unknown A client who has abruptio placentae will present with sharp or stabbing pain, tenderness, and heavy vaginal bleeding. Depending on the degree or severity of the placental separation, the client can be induced for labor or scheduled for cesarean section.

A nurse is caring for a client with pre-eclampsia who has a prescription for infusion of magnesium sulfate. Which of the following actions will be implemented by the nurse? (Select all that apply.)

Monitor urine output Assess deep tendon reflexes Rationale: Magnesium sulfate intravenous infusion is a medication given when the blood pressure is elevated in a pregnant woman to prevent seizures. Intravenous magnesium is used in the management of eclampsia and pre-eclampsia in pregnant clients, as well as for those cardiac arrhythmias, those with severe exacerbations of asthma, and critically ill clients with magnesium depletion from long-term diuretic therapy. It is contraindicated in clients with hyperkalemia, hypermagnesemia, and myasthenia gravis. Nursing assessments during a magnesium infusion include blood pressure and pulse every 10-15 minutes, respiratory rate, deep tendon reflexes, and urine output, particularly for clients with impaired renal function. IV solutions should be diluted to 20% or less. Cardiac monitoring is required during magnesium administration at a rate of >20 mEq/5 hours. An early sign of magnesium toxicity is a loss of deep tendon reflexes, decreased muscle strength, and respiratory depression. The patellar reflex disappears before onset of respiratory depression. Reflexes will be slowed if magnesium toxicity is present. Pupillary responses are not monitored. Although the respiratory rate may decrease in toxicity, it is not necessary to monitor oxygen saturation continuously.

A nurse is caring for a client who is at 36 weeks' gestation. The client has 3 young children at home who have sick classmates at school and asks about immunity in a newborn. Which of the following statements is true concerning immunity in a newborn?

Neonates have IgG antibodies from the mother and produce IgM in utero. Rationale: IgG antibody produced by the mother crosses the placenta to provide passive acquired immunity to certain bacterial pathogens. This occurs during the third trimester. The fetus also begins to produce IgM antibody by the end of the third trimester. At birth, these are the only antibodies the neonate has, but breastfeeding supplies IgA through colostrum and breastmilk.

Medications use in maternal/newborn

Nifedipine is a calcium channel blocker used as an antihypertensive medication. It can be administered to clients who have gestational hypertension. Pyridoxine, or vitamin B6, is a vitamin supplement that is prescribed to clients who have hyperemesis gravidarum. Protamine sulfate is a medication administered to treat a heparin overdose.

A client presents for an initial prenatal assessment, reporting that her last menstrual period began on January 1 and ended on January 5. She notes she had unprotected intercourse on January 15 and some spotting on January 22. According to Naegele's rule, which of the following is the estimated date of delivery?

October 8 Rationale: To arrive at the estimated date of delivery, Naegele's rule uses the first day of the date of the last normal menstrual period minus 3 months plus 7 days. Therefore, this client's estimated date of delivery is (January 1) - 3 months plus 7, or October 8. Naegele's rule assumes the client will have a 28-day cycle. The rule is not as accurate when the client has a longer or shorter menstrual cycle.

A nurse is providing dietary teaching to a client who is at 20 weeks of gestation and has a new prescription for ferrous sulfate. The nurse should recommend which of the following beverages to the client for increasing the absorption of the medication?

Orange juice Rationale: The nurse should instruct the client to take ferrous sulfate with orange juice to increase absorption. A well-balanced diet rich in citrus fruits, melons, and strawberries also helps to increase the absorption of ferrous sulfate, or iron. The most common prescribed nutrition supplement for clients who are pregnant is ferrous sulfate, or iron. A number of dietary factors can affect the absorption rate of iron. For instance, foods and beverages containing vitamin C and meats containing heme iron increase the absorption. A diet high in fiber that includes 2 L of fluid intake daily will help clients to avoid constipation, which is a common adverse effect of iron supplementation. Iron is best absorbed when taken on an empty stomach. Spinach, egg yolks, Swiss chard, tea, coffee, and milk decrease iron absorption. wait to consume them until 1 hr after taking ferrous sulfate.

A nurse is caring for a client who is pregnant and experiencing backaches. Which of the following measures should the nurse tell the client to take to help relieve backaches? (Select all that apply).

Perform the pelvic rock exercise every day. Position the knees higher than the hips when sitting. Rationale: Backache is a common discomfort of pregnancy. The client can alleviate this by performing pelvic rock or tilt exercises. These exercises stretch the muscles of the lower back and help relieve lower back pain. The client can perform these exercises while standing, sitting in a chair, lying on the floor, or on their hands and knees. Other interventions, such as using a lumbar support pillow and sitting with knees higher than the hips, can lessen naturally increasing lumbar curvature and decrease discomfort. Interventions to prevent aggravating back discomfort during pregnancy include instructing the client about proper body mechanics. The client should use their leg muscles to lift objects off the floor while bending at their knees and using their feet as a base to maintain balance. To lift objects, the client should keep the object close to their chest and avoid raising the object above their chest. instruct the client to avoid the use of hot tubs or saunas during pregnancy. Sleeping on the left side is recommended during pregnancy Sleeping in a supine position can result in maternal supine hypotension. This position is not recommended, because it exerts pressure on the major blood vessels, such as the vena cava.

Eating imbalances during pregnancy

Physiological anemia is a normal response to pregnancy caused by expansion of the plasma volume to a greater degree than increase in red blood cells. The result is a dilute blood volume with relatively decreased hemoglobin and hematocrit. The acceptable ranges for hemoglobin and hematocrit are lower during pregnancy. Pica refers to cravings for nonnutritive substances, such as dirt, clay ice, and starch, which can occur during pregnancy. Clients who have pica consume these nonnutritive substances instead of nutritious food. This can cause low maternal hemoglobin levels.

A nurse is assessing a client at 34 weeks' gestation who complains of feeling faint. Her blood pressure while supine is 100/60 mmHg. Which of the following nursing interventions is most appropriate?

Place the client lying in the left lateral recumbent position and recheck blood pressure in 5 minutes in the left arm Rationale: During pregnancy, maternal positioning can affect blood pressure. Blood pressure usually decreases in the first and second trimester as the circulation expands and as hormonal changes result in dilation of blood vessels. It usually recovers to pre-pregnancy levels in the third trimester. The client should be placed in a left lateral recumbent position to reduce pressure on her blood vessels (vena cava syndrome), which improves venous return to the heart. The blood pressure should be rechecked in 5 minutes. The blood pressure should be checked in the left arm, as checking it in the right arm may result in a falsely lower blood pressure measurement, since that arm is now positioned above the heart. Placing the client in the supine position is likely to compress maternal blood vessels, resulting in hypotension. Clients in a supine position or prolonged standing during pregnancy can experience symptoms of hypotension

A client at 24 weeks gestation arrives with painless, bright red vaginal bleeding. Which of the following conditions does the nurse suspect in this client?

Placenta previa Rationale: In placenta previa sudden painless, bright red vaginal bleeding occurs. Placenta previa is characterized by abnormal implantation of the placenta on the lower part of the uterus. As the cervix begins to dilate, the lower uterine segment separates from the upper segment. The placenta is unable to stretch and accommodate the changing cervix, resulting in painless, bright red vaginal bleeding. Intravenous therapy. This would be prescribed by the physician to replace the blood that was lost during bleeding. When placenta previa is diagnosed or suspected, vaginal examinations should be avoided, as this may initiate hemorrhage that is potentially fatal for both mother and fetus. External monitoring should be used and volume replacement may be necessary.

Normal laboratory results during pregnancy.

Platelet 150-450 000/mm^3. Hgb 12-16 g/dL WBC 10-16 000/mm^3 Hct 37-47%

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count 135,000/mm^3 Rationale: The nurse should notify the provider of this result because it is an indication of thrombocytopenia. A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation. normal platelet count 150-450 000/mm^3 The nurse should notify the provider if the client's Hgb is below 11 g/dL because this is an indication of anemia. The nurse should notify the provider if the client's WBC count is greater than 15,000/mm^3 because this is an indication of infection. The nurse should notify the provider if the client's Hct is under 33% because this is an indication of anemia.

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking?

Prepare for delivery of the infant Rationale: Delivery is considered when a biophysical profile score of 6 or lower is obtained at or after 36 weeks of gestation or with a score of 4 or lower at any gestational age. A biophysical profile score of 4 indicates possible chronic fetal asphyxia.

A nurse is caring for a client at 38 weeks gestation who reports severe sudden abdominal "ripping" pain when receiving an oxytocin infusion during labor. The client's heart rate is 130/min, and she is tachypneic. The fetal heart rate monitor reveals minimal variability and bradycardia. Which of the following tasks does the nurse anticipate?

Prepare for immediate cesarean delivery Rationale: This describes uterine rupture, a life-threatening emergency. It can be complete, which involves the uterine wall and peritoneal cavity, with internal bleeding. Uterine rupture can also be incomplete, which refers to the dehiscence of a scar after a prior cesarean birth. There may not be internal bleeding present with incomplete rupture. The Trendelenburg position is recommended for uterine rupture. The knee-to-chest position is recommended for uterine cord prolapse. Risk factors include uterine trauma, including previous cesarean section; congenital uterine abnormalities; polyhydramnios, multi-fetal gestation, and large for gestational age; hyperstimulation of the uterus, including administration of oxytocin; forceps-assisted delivery, and external or internal version of the fetus. Oxytocin is used to stimulate uterine contractions, either to initiate or to augment labor. It increases the risk of uterine rupture, particularly in women who have had a prior cesarean section. Oxytocin is administered by an infusion pump and the dose is typically increased until labor progress is normal, or strong contractions occur at two- to three-minute intervals. Uterine and fetal monitoring are required. Uterine tachysystole, which refers to more than 5 contractions in ten minutes, is an adverse effect that can result in fetal hypoxemia.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?

Renal agenesis Rationale: Oligohydramnios is a volume of amniotic fluid surrounding the fetus that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios. Gestational hypertension causes oligohydramnios

A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy?

Report of fetal movement by the client Rationale: Quickening (the report of fetal movement felt by the client) begins around 18 to 20 weeks of gestation and is considered a presumptive indication of pregnancy. Chadwick's sign (the violet coloration of the cervix during pregnancy) is visible around 6 weeks of gestation and is considered a probable indication of pregnancy. Braxton-Hicks contractions might be reported by the client as early as 20 weeks of gestation and are considered a probable indication of pregnancy. The fetal heart rate can be auscultated with Doppler ultrasound around 10 to 12 weeks of gestation and is considered a positive indication of pregnancy.

A nurse is caring for a client who has severe preeclampsia and is receiving a magnesium sulfate IV infusion. The nurse should monitor the client for which of the following manifestations as a sign of magnesium sulfate toxicity? (Select all that apply.)

Respiratory rate less than 12/min Decreased level of consciousness Rationale: Magnesium sulfate is administered intravenously to clients who are pregnant and have severe preeclampsia to prevent seizure activity. Magnesium causes the cerebral blood vessels to dilate and can suppress the function of the central nervous system. A decreased level of consciousness and a respiratory rate of less than 12/min are manifestation of central nervous system depression and of magnesium sulfate toxicity. Other manifestations of magnesium sulfate toxicity include : urinary output of less than 30 mL/hr, absence of deep tendon reflexes, blurred vision, muscle weakness, and cardiac arrest. Magnesium is excreted by the body through the kidneys. If not excreted properly, it can cause magnesium toxicity. Calcium gluconate or calcium chloride can be administered via IV to reverse the effects of magnesium toxicity.

Rho-gam is administered to ____ mothers with a ____ fetus/infant.

Rh-, Rh+ Rationale: Individuals with Rh-negative blood develop antibodies after exposure to Rh-positive blood. Rhogam is an immune globulin given to Rh-negative women in pregnancy if the father is not conclusively shown to be Rh-negative to prevent sensitization of Rh-negative women who have had a fetomaternal transfusion of Rh-positive fetal RBCs. A standard dose of RhoGAM is administered as an IM injection at 28 weeks gestation to prevent the formation of antibodies against Rh-positive red blood cells. It is also given after exposure risks that occur after 28 weeks, including amniocentesis, second-trimester miscarriage/abortion, external version attempt, and within 72 hours of delivery if the baby is Rh-positive. Rhogam is not administered if the mother and the fetus's blood type match (the same). There is no risk of antibody formation leading to fetal destruction if the mother is Rh+ yet the fetus is Rh-. Rhogam is not indicated in these cases. Rhogam promotes the destruction of fetal Rh-positive blood cells before the mother forms antibodies against them. It is given to Rh-negative women to prevent antibody formation that could attack Rh-positive fetal red blood cells in a subsequent pregnancy.

A nurse is counseling a 45-year-old pregnant woman regarding the risks associated with amniocentesis. Which of the following is NOT a risk associated with this procedure?

Seizure Rationale: Seizures are not associated with amniocentesis.

The nurse is performing a prenatal assessment on a pregnant client in her third trimester. Vital signs are within normal limits. Which of the following signs does the nurse expect? (Select all that apply)

Shortness of Breath Constipation Rationale: Shortness of breath occurs in the third trimester because of the pressure exerted by the enlarging uterus on the diaphragm, which in turn decreases the vital capacity of the lungs. Constipation occurs in the third trimester due to sluggishness of the intestines brought about by increased levels of progesterone. Changes a pregnant woman may expect in the third trimester include Braxton Hicks contractions, backaches, dyspnea, heartburn, spider veins, varicose veins and hemorrhoids; frequent urination and urinary leakage.

A nurse is caring for a client who is suspected to have an ectopic pregnancy. Which of the following findings should the nurse identify as a manifestation of ectopic pregnancy?

Shoulder pain Rationale: An ectopic pregnancy can result in the rupture of a fallopian tube, which causes bleeding into the peritoneal cavity. The resulting collection of blood can irritate the diaphragm and cause referred shoulder pain. A client who is experiencing an ectopic pregnancy will report a delay in their menstrual cycle. A progesterone level that is lower than the expected reference range is an indication of ectopic pregnancy. An ectopic pregnancy is a pregnancy that is implanted outside of the uterus, typically in one of the fallopian tubes. Manifestations of ectopic pregnancy usually present at 5 to 8 weeks of gestation and include abdominal pain, tenderness, and progesterone levels below the expected range. An ectopic pregnancy is considered an emergency and manifestations should be reported to the provider promptly. If left untreated, the fallopian tube can rupture, resulting in intra-abdominal hemorrhaging and decreased fertility.

A nurse is caring for a client who is in the third trimester of a high risk pregnancy who has had a positive contraction stress test (CST). Which of the following is true of a positive CST?

Shows late decelerations of the fetal heart rate with most contractions Rationale: If decelerations occur with >50% of the contractions, this results in a positive CST result. A CST is performed after a non-stress test (NST) is nonreactive or equivocal, not before. A CST Shows a fetal rate out of range the expected limits for the average fetus. Fetal health is evaluated, in part, by assessment of fetal heart rate (FHR) patterns. The nonstress test (NST) and the contraction stress test (CST) are used to test fetal heart rate in the third trimester. The goal of testing the fetal heart rate with these tests is to identify fetuses at risk of intrauterine death or neonatal complications. This provides a potential opportunity for interventions, including delivery, that may prevent adverse outcomes.

Pre-Eclampsia Facts

Signs of pre-eclampsia: - Proteinuria - Hypertension Risk factors: - First pregnancy - Teen mothers - Mothers over 40 - Multiple gestation - Obesity - Diabetes The blood pressure elevation along with protein in the urine is a classic finding in preeclampsia and eclampsia. Intravenous magnesium sulfate is used in the management of eclampsia and pre-eclampsia in pregnant clients

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration?

Slow trickle of bright vaginal bleeding and a firm fundus Rationale: The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration. Other considerations: The nurse should monitor for continuous and excessive vaginal bleeding in the presence of a flaccid uterus to identify that the blood is coming from the uterus. The most common cause of this occurrence is a full bladder or retained placental fragments. The nurse should monitor for a report of increasing pain and pressure in the perineal area to identify a vulvar hematoma. When the nurse massages the uterus, it will contract and help move pooled blood in the uterus to the vaginal opening resulting in a gush of rubra lochia when the uterus is massaged

A nurse is caring for a 35-year-old pregnant client who must undergo an amniocentesis. Which of the following are birth defects that are detected by amniocentesis? Select all that apply.

Tay-Sachs disease Cystic fibrosis Down syndrome Rationale: Amniocentesis is a prenatal test performed on clients at risk of prenatal complications, to test for genetic anomalies associated with certain birth defects. The test is done by inserting a large needle into the abdomen and withdrawing a small amount of fluid from the amniotic sac surrounding the fetus. The fluid is then analyzed for specific neural tube defects and genetic markers associated with congenital birth defects, including Tay-Sachs disease, cystic fibrosis, and Down syndrome. Amniocentesis is performed between the 14th and 20th week of gestation to detect neural tube defects and a chromosomal defects associated with congenital anomalies. Amniocentesis can also be used to determine sex of the fetus. In the final trimester of pregnancy, amniocentesis can be used to diagnose fetal lung maturity. Indications include maternal age > 35 years; family history of chromosomal abnormality, inborn errors of metabolism, or neural tube defect.

A nurse is caring for a pregnant client who is having an initial prenatal visit at 30 weeks' gestation. Which of the following vaccines are considered safe for administration in this client?

Tetanus, diphtheria, and pertussis Rationale: Tdap vaccine protects against tetanus, diphtheria, and whooping cough (pertussis). Tdap is considered safe in pregnancy. It is recommended for all pregnant women from 27 to 36 weeks' gestation in order to provide passive immunity against pertussis to the newborn. Pertussis is a respiratory infection caused by Bordetella pertussis and is commonly known as whooping cough. Pregnant women can receive killed influenza vaccine by injection throughout pregnancy, which is recommended for all pregnant women. Live attenuated virus vaccines are contraindicated during pregnancy and within four weeks of pregnancy. They include nasal influenza vaccines (LAIV), MMR, and varicella vaccine. Live attenuated viral vaccines are contraindicated in pregnancy, and women who receive the vaccines should also be counseled to avoid pregnancy within 4 weeks of receiving these vaccines. Varicella contains live virus and is contraindicated in pregnancy. It causes chicken pox and shingles, but the risk of contracting the virus is low in pregnancy since most women of childbearing age have immunity from prior infection.

While reviewing the medical record of a client who is pregnant, a nurse reads the following data: G3 T1 P0 A1 L1. Based on this information, what does the nurse know is true about the client? (Select all that apply).

The client has had two prior pregnancies. The client has delivered one newborn at term. The client has had no preterm deliveries. The client has one living child. Rationale The GTPAL system is a standard system of classifying pregnancies and maternal history. "G" stands for "gravida" and indicates the total number of times the client has been pregnant, including the current pregnancy. "T" stands for "term" and indicates how many pregnancies/births/deliveries the client carried to term, beyond 37 weeks of gestation. "P" stands for "preterm" and indicates how many deliveries the client has had prior to 37 weeks of gestation. "A" stands for "abortions" and indicates how many spontaneous, therapeutic, or elective abortions the client has had. "L" indicates how many living children the client has.

A charge nurse on a labor and delivery unit is providing an inservice for staff about diagnostic tests used during pregnancy to measure fetal and maternal well-being. Which of the following examples will the charge nurse use as a common indication for non-stress test (NST) in a pregnant client?

The client is 41 weeks gestation Rationale: A non-stress test (NST) is a procedure that is performed by attaching a fetal monitor to a pregnant client and recording the fetal heart rate and activities; the mother pushes a button whenever she feels the baby move. A NST would most likely be indicated for a pregnant client who is past her due date. A fetal non-stress test is a simple, non-invasive test performed in pregnancies at > 28 weeks gestation. No stress is placed on the fetus during the test. One monitor is placed on the mother's abdomen to measure fetal heart rate and another is placed to measure contractions. Fetal movement, heart rate and the reactivity of the fetal heart rate to movement is measured for 20-30 minutes. Other considerations: The client would most likely need an amniocentesis with an abnormal ultrasound, the client's first child had Down syndrome, the client is 39 years old

A nurse is assessing a client who had been treated for dyspareunia. Which of the following indicates an expected outcome after treatment?

The client reports little to no pain during sexual intercourse Rationale: Relief or resolution of pain during sexual intercourse is an expected outcome. Dyspareunia refers to painful intercourse. This condition can result in a diminished quality of life for the client. Causes include cancer, pelvic inflammatory disease, a history of sexual abuse, depression, anxiety, obstetrical trauma, and hormonal imbalance.

A charge nurse is assigning clients on a medical surgical unit. Which of the following clients should not be assigned to a nurse who is in the first trimester of pregnancy?

The client who has AIDS and toxoplasmosis infection Rationale: Toxoplasmosis is a TORCH infection that can cross the placental barrier, so a nurse who is pregnant should not be assigned to care for this client. TORCH infections are common infections associated with congenital anomalies. They include: Toxoplasmosis Other (syphilis, varicella-zoster, parvovirus B19) Rubella Cytomegalovirus Herpes infections

A nurse is caring for a new client who reports a positive home pregnancy test. She is seen in the clinic on January 6, and her last menstrual period was October 6. Which of the following does the nurse expect (select all that apply)?

The fetal heart rate can be detected by Doppler. The expected date of delivery by Naegele's rule is July 13. Rationale: Naegele's rule allows calculation of an expected date of delivery by subtracting 3 months from the date of the last menstrual period then adding 7 days. Accuracy is affected by the length and regularity of the client's menstrual cycle. In this case, the estimated date of delivery is July 13. Detection of fetal heart rate by Doppler is possible from 10 to 12 weeks' gestation. Other considerations: Fetal movement is usually sensed by the mother at 18-20 weeks' gestation in primigravidas and 14-16 weeks' gestation in multigravidas. The onset of maternal awareness of fetal movement is known as "quickening." Urinary frequency is a common finding in the initial trimester of pregnancy due to hormonal fluctuation and anatomical changes in the urinary tract. Dysuria, back pain, or a fever are abnormal and suggest a urinary tract infection. The fundus height is used to measure uterine growth and correlates closely in centimeters with the number of weeks' gestation after 20 weeks.

A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect?

The fundal height measures greater than gestational age. Rationale: Clients with placenta previa often measure slightly larger than expected because the fetus remains higher in the uterus. A client with placenta previa presents with a soft, non-tender abdomen. Painless vaginal bleeding is indicative of placenta previa until otherwise ruled out by ultrasound.

A nurse is providing care to a client after delivery of a healthy baby. While assessing the client's extremities, the nurse notes tenderness, warmth, and redness of the lower extremity. Which of the following does this finding most likely represent?

Thrombophlebitis Rationale: Tenderness, warmth, and redness of the leg are the symptoms of thrombophlebitis. Thrombophlebitis is vein inflammation related to a blood clot. It occurs more commonly in pregnancy and the postpartum period. Postpartum deep vein thrombosis (DVT) and superficial thrombophlebitis in the postpartum period may occur as a result of trauma to the pelvic veins from pressure exerted by the presenting fetal part. Other pregnancy related changes that increase the risk of thrombophlebitis or DVT include impaired circulation and hypercoagulability related to the increased production of estrogens during pregnancy. Thrombosis that involves only the superficial veins of the leg or thigh is unlikely to result in pulmonary emboli

Third trimester of pregnancy - For a client who has a normal prepregnancy BMI, the expected third-trimester weight gain for a singleton pregnancy is 0.35 to 0.50 kg/week (0.8 to 1lb). Recommended weight gain for overweight BMI is 0.3 kg (0.6 lb) and for obese BMI is 0.2 kg (0.5 lb) per week. - blood pressure stable or slightly rising at term. -resting heart rate to be approximately 10 to 30 beats per minute faster than the prepregnancy rate. The presence of S3 is usually noted in the second trimester and the splitting of S2 during the third trimester. - fundal height in centimeters (+/- 2 cm) - approximates gestational age in weeks - fetal heart rate expected range is 110 to 160 beats per minute. - Fetal activity decreases during fetal sleep, which may last up to 40 min. - gestational diabetes mellitus - if a client is experiencing vaginal bleeding or fluid leak, a bloody show indicates cervical dilation and con

Unexpected findings: - A proteinuria of 2+ or greater by urine dipstick with elevated blood pressure suggests preeclampsia. - The presence of nitrites, ketones, leukocytes, or a large amount of glucose requires additional evaluation by the provider. -prompt evaluation is needed if the client reports fewer than 3 fetal movements within an hour. Less than 10 movements in 2 hr can indicate fetal distress. The nurse should instruct the client to be evaluated. The provider will likely prescribe a nonstress test to confirm fetal well-being. - Clients with a hemoglobin of less than 11 g/dL and a hematocrit less than 33% are considered to have anemia. - if B streptococcus ß-hemolytic is positive, treat with penicillin. - A client report of pruritic, copious, purulent, or malodorous vaginal discharge requires further evaluation as these findings may suggest infection​​​​​​​. - Right upper quadrant pain, especially after ingestion of high-fat food, can indicate cholelithiasis​​​​​​​. - Evaluate further if the client reports dysuria, flank pain, fever, and/or chills, as these findings may indicate cystitis or pyelonephritis​​​​​​​. - Brisk deep tendon reflexes (clonus) are unexpected and can indicate preeclampsia with severe features. Report this finding to the provider, as this neurologic finding can indicate that the client is at significant risk for a seizure​​​​​​​.

A nurse is caring for a client who has preeclampsia and is receiving intravenous magnesium sulfate for the prevention of seizures. Which of the following findings should the nurse report to the provider?

Urinary output of 80 mL every 4 hr Rationale: A urinary output of 80 mL every 4 hr is outside the expected reference range of at least 100 mL every 4 hr. The nurse should report this finding to the provider. A magnesium level of 4 mEq/L is within the expected reference range of 4 to 7 mEq/L for a client who has preeclampsia Magnesium sulfate is a mineral and electrolyte replacement indicated for the prevention of seizures in a client who has preeclampsia or eclampsia. Indications for use include: • Eclampsia/Preeclampsia • Magnesium deficiency • Seizures • Bronchodilation • Torsade de Pointes

A nurse is admitting a client at 12 weeks' gestation for treatment of a deep vein thrombosis. Which of the following medications is contraindicated in pregnancy?

Warfarin Rationale: Warfarin is associated with fetal malformations and is contraindicated in early pregnancy through the first trimester for most indications. It is considered category D for women with high-risk mechanical heart valves. Pregnancy increases the risk of venous thromboembolism four to five fold. DVT occurs three times as often as PE. Warfarin is an anticoagulant used in treatment of venous thromboembolic disease, including deep vein thrombosis, pulmonary embolism, atrial thrombosis, atrial fibrillation. It interferes with synthesis and activation of vitamin K dependent clotting factors. Prothrombin time (PT) and International Normalized Ratio (INR) are used to monitor the therapeutic effects of the drug.

A nurse is assessing a client at 26 weeks' gestation who complains of occasional contractions. Which of the following factors increases the client's risk of preterm labor? (Select all that apply).

Urinary tract infection Multifetal pregnancy Diabetes mellitus Rationale: Genital infections, such as a urinary tract infection, are risk factors for preterm labor because of the immune system's response to the infection. Preterm labor is usually suppressed if the fetal lungs have not matured, if there are no contraindications and the cervix is dilated less than 4 cm. Fetal lung maturity is assessed by amniocentesis and analysis of the L/S (lecithin/sphingomyelin) ratio. A multifetal pregnancy is a risk factor for preterm labor due to the over-distention of the uterus. Chronic medical conditions, such as diabetes mellitus, are risk factors for preterm labor. Clients who are over 30 years of age are considered to have high-risk pregnancies, including an increased risk for preterm labor. Low pre-pregnancy weight is associated with preterm labor. Preterm labor refers to onset of rhythmic uterine contractions that result in cervical changes, usually between the 20th and 37th-week gestation. This is a period of fetal viability but before fetal maturity. Management includes suppression of preterm labor when tests show immature fetal pulmonary development and cervical dilation is less than 4 cm, in the absence of contraindications to the continuation of the pregnancy. Risk factors include infections, chronic medical conditions, advanced maternal age, multifetal gestation, low pre-pregnancy weight, placental changes, maternal or fetal stress, uterine over-distention, obesity, and amniotic fluid abnormalities.

A nurse is reviewing the laboratory values of a client who has severe hyperemesis gravidarum (severe nausea and vomiting during pregnancy). Which of the following laboratory findings should the nurse identify as a manifestation of this condition?

Urine ketones present Rationale: The presence of ketones in the urine is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gravidarum. The breakdown of fat stores provides the client with more energy. Hyperemesis gravidarum is excessive nausea and vomiting that occurs during pregnancy, which causes an imbalance of nutrition and electrolytes. Clients who have hyperemesis gravidarum are unable to digest nutritious foods and the body will start using fat stores as a fuel. This results in ketosis, causing the client's urine to have high levels of ketones present. Manifestations of hyperemesis gravidarum include weight loss, dehydration, nausea, vomiting, dry mucous membranes, and decrease skin turgor. Laboratory results might show manifestations of dehydration, such as an altered hematocrit, electrolyte imbalances, and the presence of ketonuria. Nursing measures are focused on restoring fluid balance: observing for signs of metabolic acidosis due to hypovolemia or metabolic alkalosis due to loss of gastric secretions; providing oral care; and providing a quiet restful environment that is free from odors.

A nurse is counseling a 45-year-old pregnant woman regarding the risks associated with amniocentesis. What are risks associated with this procedure?

Uterine contractions or tenderness, fever and chills are all symptoms that could indicate infection following amniocentesis. These symptoms should be reported to the physician immediately. There is a small risk of miscarriage associated with amniocentesis, but this risk is very small (approximately 0.5%). Leakage of amniotic fluid can occur following amniocentesis. This leakage generally stops within a couple of days; if it doesn't, the physician should be notified. Women should be counselled to rest in bed should leakage of amniotic fluid occur. A small amount of vaginal bleeding can occur following amniocentesis. If it is heavy or lasts longer than a day or two the physician should be notified. Women should be counselled to rest in bed should bleeding occur. Amniocentesis is a procedure in which a hollow needle is inserted into the uterus, to screen for chromosomal abnormalities, neural tube defects, and genetic anomalies in a fetus. It is typically performed between 14 and 16 weeks gestation. Amniocentesis is also performed to test fetal lung maturity between 32 and 39 weeks' gestation.

A nurse is teaching a client who is at 32 weeks of gestation about findings to immediately report to the provider. Which of the following manifestations should the nurse include?

Watery discharge from the vagina Rationale: A sudden watery discharge from the vagina could indicate that the amniotic membranes have ruptured. This finding should always be immediately reported to the physician. Although spontaneous rupture of the membranes after 37 weeks is an expected finding, the occurrence should always be immediately reported to the physician. The nurse should inform pregnant clients about the manifestations of potential pregnancy complications, such as swelling of the face, chills, vaginal bleeding, severe headaches, and visual disturbances. If the client experiences any of these, the provider should be notified immediately to allow for prompt intervention. Other considerations: Swelling of the ankles is a common discomfort during pregnancy and can be relieved by sitting with the legs elevated. Heartburn occurs during pregnancy due to pressure on the stomach from the enlarging uterus. It can be relieved by eating smaller, more frequent meals. Supine hypotension occurs when a client feels lightheaded when lying on their back. The nurse should instruct the client to use the side-lying position to relieve the pressure of the uterus on the vena cava.

A 23-year-old client has come into the health care clinic for her first prenatal visit. The nurse is reviewing the characteristics and expectations of pregnancy. Match each with the trimester of pregnancy it best describes.

While each pregnancy is different, many women experience significant changes throughout pregnancy that are characteristic to the changing trimesters. Uterine pain and significant bleeding are never normal. During the first trimester, the pregnant woman may experience nausea and vomiting, breast tenderness, emotional lability, and feelings of ambivalence toward the pregnancy. The second trimester is a slight reprieve from the early feelings of discomfort and the mother may have a renewed sense of energy compared to the first trimester. It is during the second trimester that the first flutterings of the baby can be felt. During the third trimester, the mother's body starts to prepare for childbirth and she may experience Braxton-Hicks contractions, frequent urination, varicose veins, and peripheral edema.

Difference between preeclampsia and HELLP syndrome. Preeclampsia (persistent headache, visual changes, facial edema, epigastric pain). Reported epigastric pain after 20 weeks can indicate preeclampsia with severe symptoms. A proteinuria of 2+(between 100 and 300 mg/dL) or greater accompanied by elevated blood pressure after 20 weeks of gestation suggests preeclampsia. HELP syndrome includes those of preeclampsia plus hemodialysis

from NIH webpage: Diagnostic criteria of severe preeclampsia were systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110mmHg in two separate readings more than four hours apart, new onset cerebral or visual disturbance, elevated liver enzymes, epigastric pain, pulmonary edema, low platelet count, progressive renal insufficiency. The presence of the following three criteria was required for the diagnosis of HELLP: (1) hemolysis (serum lactate dehydrogenase level of higher than 600IU/L or total bilirubin level of higher than 1.2mg/dL or decreased hemoglobin and hematocrit levels); (2) low platelet count (lower than 150000 cells/mm3); and (3) elevated liver enzymes (aspartate aminotransferase level of higher than 40IU/L and/or alanine aminotransferase level of higher than 40 IU/L).