maternal newborn part 1

Slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation

quickening

Maternal hypotension & fetal hypoxia may occur, which is referred to as

supine hypotensive syndrome or supine vena cava syndrome.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine

A. 480 mL urine output in 24 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding Incorrect Answers: B. A blood pressure of 144/92 mm Hg is nonurgent because it is an expected finding for a client who has preeclampsia. Therefore, there is another finding that is the priority. C. +2 edema of the feet is nonurgent because it is an expected finding for a client who is at 35 weeks of gestation and has preeclampsia.

A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply) A. Client has delivered one newborn at term B. The client has experienced no preterm labor C. Client has been through active labor D. Client has had two prior pregnanciesE. Client has one living child

A. Client has delivered one newborn at term D. Client has had two prior pregnancies E. Client has one living child

A nurse is caring for a client who is pregnant and states that her last menstrual period was April 1 2013. Which of the following is the client's estimated date of delivery? A. Jan 8 2014 B. Jan 15 2014 C. Feb 8 2014 D. Feb 15 2014

A. Jan 8 2014

A nurse is caring for a school-Question Feed aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? A. Slurred speech B. Hemoglobin level of 9 g/dL C. Hematuria D. Pain level of 7 on FACES scale

A. Slurred speech The nurse should identify that slurred speech in a child who has sickle cell anemia is an indication of a stroke. The nurse should report this finding to the provider immediately.

viability

Ability of the fetus to survive outside the womb

A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts

B. 3+ deep tendon reflexes Deep tendon reflexes of 3+ or greater can indicate preeclampsia and should be reported to the provider.

A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? A. Platelet count 97,000/mm^3 B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22 mg/dL

B. Deep tendon reflexes 4+ Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures. A. With preeclampsia, a client's platelet count is usually below 100,000/mm^3. There is no need to report this finding. C. With preeclampsia, a client's proteinuria is usually above 1+ on a urine reagent strip. There is no need to report this finding. D. With preeclampsia, a client's BUN level is usually above 20 mg/dL. There is no need to report this finding.

A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following would be included? (Select all that apply) A. Montgomery's glands B. Goodall's sign C. Ballottement D. Chadwick's sign E. Quickening

B. Goodall's sign C. Ballottement D. Chadwick's sign

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? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%

B. Platelet count 135,000/mm^3 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 HELL syndrome and requires further evaluation. Incorrect Answers: A. The nurse should notify the provider if the client's Hgb is below 11 g/dL because this is an indication of anemia. C. 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. D. The nurse should notify the provider if the client's Hct is under 33% because this is an indication of anemia.

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? A. Severe hypotension B. Proteinuria C. Elevated platelet count D. Seizures

B. Proteinuria The nurse should expect a client with preeclampsia to have proteinuria and impaired kidney function.

the point and time when an infant has the capacity to survive outside the uterus. there is a specific weeks of gestation ; however infants born between 22 to 25 week are considered the viability threshold

viability

rebound of unengaged fetus

Ballottement

A nurse in a prenatal clinic is caring or a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following is an appropriate response by the nurse? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output."

C. "This is due to the weight of the uterus on the vena cava."

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

C. A child who has sickle cell anemia and a urine specific gravity of 1.030 A child who has sickle cell anemia must maintain adequate hydration because dehydration could cause sickle cell crisis that can occlude the child's circulation.

A nurse is reviewing the laboratory report for a client with suspected HELL syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder? A. Elevated hemoglobin B. Elevated creatinine clearance C. Elevated liver enzymes D. Elevated platelet count

C. Elevated liver enzymes The nurse should expect a client who has HELLP syndrome to have elevated liver enzymes. HELL refers to hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). This syndrome is a severe form of preeclampsia. A. The nurse should expect a client who has HELL syndrome to have a decreased hemoglobin level. B. The nurse should expect a client who has HELL syndrome to have decreased creatinine clearance. D. The nurse should expect a client who has HELL syndrome to have a decreased platelet count.

A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus B-hemolvtic D. 1-hour glucose tolerance test

C. Group B streptococcus B-hemolytic The nurse should obtain a vaginal/anal group B streptococcus -hemolytic (GBS) culture at 35 to 37 weeks gestation to screen for infection. Prophylactic antibiotics should be given during labor to clients who are positive for GBS.

A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine

C. Oxytocin Oxytocin is a uterotonic medication that causes the uterus to contract and reduces excessive uterine bleeding. A. Terbutaline is a tocolytic medication that causes uterine relaxation and is used to treat preterm labor. It is not an appropriate medication to treat uterine atony. B. Magnesium sulfate is a tocolytic medication used to treat preterm labor and decrease the risk of eclamptic seizures. It is not an appropriate medication to treat uterine atony. D. Methylergonovine is a uterotonic medication that has an adverse effect of hypertension. Therefore, this medication is contraindicated for a client who has preeclampsia.

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? Question Feedback A. Eggs B. Squash C. Kale D. Tofu

Correct Answer: A. Eggs The nurse should encourage the client to increase consumption of foods rich in vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs.

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child B. Apply pressure for 1-2 min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D. Check the child's blood glucose level every 4 hr

Correct Answer: A. Initiate protective-environment isolation for the child The nurse should suggest protective-environment isolation for the child, which consists of a private room with positive air pressure and no live flowers; nurses must don a respirator mask, gloves, and gown prior to entering the child's room. A child who has aplastic anemia has decreased RBCs, platelets, and WBCs, causing immune suppression and increasing susceptibility to infection.

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

Correct Answer: A. Lentils The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. A

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

Correct Answer: A. Monitor the child's oxygen saturation level When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level.

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements Andicates that the client understands the instructions? A. "I need to stay active to prevent blood clots in my legs." B. "If I have a bad headache, I can take aspirin to get rid of it." C. "I should eliminate uncooked foods from my diet for now." D. "I should eat more iron-fortified cereal to strengthen my blood."

Correct Answer: C. "I should eliminate uncooked foods from my diet for now." The client can help prevent infection by eating thoroughly cooked foods.

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione

Correct Answer: C. Give the child flavored popsicles Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles as a source of fluid.

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the client's tongue B. Decreased pulse rate C. Paresthesias in the hands and feet D. Joint pain in the extremities

Correct Answer: C. Paresthesias in the hands and feet The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of pernicious anemia.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

Correct Answer: D. Iron toxicity A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body.

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice with an enlarged liver D. Petechiae and ecchymosis

Correct Answer: D. Petechiae and ecchymosis A client who has aplastic anemia will have manifestations of petechia and ecchymosis. Dyspnea on exertion also can be present.

A nurse is caring for a client who is at 16 weeks gestation and has severe iron- deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? A. Use a 20-gauge needle and administer the medication using the Z-track method B. Use a 22-gauge needle and administer the medication deep into the thigh C. Use a 25-gauge needle and administer the medication into the deltoid muscle D. Use an 18-gauge needle and administer the medication into the rectus femoris muscle

Correct Answer: Use a 20-gauge needle and administer the medication using the Z-A. track method The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment

Correct Answers: A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment

A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching? A. Nausea upon awakening B. Leg cramps while sleeping C. Increased white vaginal discharge D. Blurred or double vision

D. Blurred or double vision A client who is pregnant should report experiencing blurred or double vision, as these could be a manifestation of gestational hypertension or preeclampsia.

A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions

D. Implement seizure precautions Clients who have preeclampsia with severe features are at risk for seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction equipment are readily available.

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine

D. Methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions. A. The nurse should administer terbutaline, a smooth muscle relaxant, to a client who is experiencing preterm labor. B. The nurse should administer nifedipine, a smooth muscle relaxant, to a client who is experiencing preterm labor. C. The nurse should administer magnesium sulfate to a client who has preeclampsia to lower blood pressure and minimize the risk of seizures

A nurse is assessing a client who is at 30 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse identify as an indication that the client needs a biophysical profile? A. Fundal height 30 cm B. Fetal movement count 12 kicks in 12 hours C. Fetal heart rate 136/min D. Nonreactive non-stress test

D. Nonreactive non-stress test When a non-stress test is nonreactive, the examiner will extend the duration of the test and use techniques such as vibroacoustic stimulation to try to elicit a response from the fetus. If the test is still nonreactive, the client should undergo a biophysical profile.

A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? A. Iron deficiency B. Hemolytic blood loss C. Folic acid deficiency D. Vitamin B12 deficiency

D. Vitamin B12 deficiency A client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12.

Manifestations of supine hypotensive syndrome or supine vena cava syndrome include:

Dizzy Lightheaded Palor Clammy skin

GTPAL system

G = gravidity (# of times pregnant) T = term (37 weeks or more) P = preterm birth (viability -37 weeks) A = abortion (prior to viability) L = living children ex: woman who is pregnant now, has 2 children, one born @ 38 weeks, one @ 42 weeks = 32002

softening of cervical tip

Goodell's sign

Nursing interventions for supine hypotensive syndrome or supine vena cava syndrome?

POSITIONING Left-lateral side, semi-fowler's. wedge placed under on hip if supine. Encourage these positions to alleviate pressure to the vena cava.

- medication that can cause false positive test or false negative test reult are

anticonvulsant, diuretic, and tranquilizers

changes that the client experiences that make them think they might be pregnant is called

presumtive

a client in their first pregnancy

primigravida

false contractions that are painless, irregular, and usually relieved by walking

braxton hicks contraction

deepened violet-bluish color of the cervix and vaginal mucosa

chadwick's sign

number of pregnancies

gravida

lower HCG might indicate

miscarriage or ectopic pregnancy

a client who has had two or more pregnancies

multigravida

has completed two or more pregnancies to stage of viability

multipara

a client who has never been pregnant

nulligravida

no pregnancy beyond the stage of viability

nullipara

Higher levels of hCG can indicate

-Multifetal pregnancy -Ectopic pregnancy -hydatidiform mole -down syndrome

Verifying pregnancy

-blood and urine tests provide an accurate assessment for the presence of human chorionic gonadotropin (hCG). -hCG production can start as early as the day of implantation and can be detected as early as 7 to 8 days after conception. - some medication ( such as anticonvulsant, diuretic, and tranquilizers) can cause false positive test or false negative test reult

Naegele's Rule

1) First day of LMP 2) Subtract 3 months from date of LMP 3) Add 7 Days

what are the 3 signs of pregnancy

1. Presumptive 2. Probable 3. Positive

Probable signs of pregnancy

1. abdominal enlargement 2.hegar's sign 3. chadwick's sign 4. goodell's sign 5.positive pregnancy test 6. fetal outline felt by examiner. 7. ballottement 8. braxton hicks contraction

Positive signs of pregnancy

1. fetal heart sound 2. visualization of fetus by ultrasound 3. fetal movement palpated by the examiner

Presumtive signs of pregnancy

1.amenorrhea 2. N/V 3. breast tenderness 4. urinary frequency 5. quickening 6.FATIGUE 7. uterine enlargement

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia laboratory studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add a calcium supplement to her diet

B. Advise the client to lie on her side Dizziness after a pregnant client lies flat on her back is a sign of supine hypotension, which is caused by compression of the vena cava from the weight of the pregnant uterus. Pregnant women should be advised to avoid lying in a supine position.

A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery B. Advise the client to start iron and vitamin C supplementation C. Review the medication list to determine if the client is taking an anticonvulsant D. Request an order for sickle cell anemia screening

B. Advise the client to start iron and vitamin C supplementation

softening and compressibility of lower uterus

Hegar's sign

number of pregnancies in which the fetus or or fetuses reach 20 weeks of pregnancy, not the number of fetuses

parity

has completed one pregnancy to stage of viability

primipara

changes that make the examiner suspect a client is pregnant ( primarily related to physical changes of the uterus) is called

probable signs

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (Select all that apply.) A. A client who is postmenopausal B. A client who is a vegetarian C. A middle adult male client D. A client who is pregnant E. A toddler who is overweight

Correct Answers: B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight