Maternity HESI Case Study Questions

You instruct Susan about taking her daily iron supplement. Which of the following statements should be included in the teaching session? "Take the iron supplement first thing in the morning to avoid gastrointestinal discomfort." "Drink a glass of milk along with your iron supplement." "Increase your intake of citrus fruits and juices." "If tolerated, take the iron supplement on an empty stomach."

"Increase your intake of citrus fruits and juices." --> Iron absorption is enhanced when intake of Vitamin C is increased. Citrus fruits and juices, tomatoes, melons, and strawberries are all high in Vitamin C and should be encouraged when iron supplements are prescribed. "If tolerated, take the iron supplement on an empty stomach." --> Absorption is optimal when an iron supplement is taken on an empty stomach. Pregnant women taking iron supplements should be encouraged to take supplements on an empty stomach, provided gastrointestinal distress is not a problem.

Which of the following statements would indicate that Susan understands correct information on breastfeeding? "For each feeding, I will feed Jason for five minutes on each breast so my nipples will not get sore." "To break suction, I will insert my finger into the corner of Jason's mouth before removing him from the breast." "I will wash my nipples with mild soap each day in the shower to ensure they are germ-free." "When Jason has a growth spurt, he will want to nurse more often, which will increase my milk supply."

"To break suction, I will insert my finger into the corner of Jason's mouth before removing him from the breast." --> This statement contains correct information about breaking suction. Breaking suction before removing the infant from the breast is important in preventing nipple trauma, such as cracking and soreness. Nipple cracking and soreness can also be prevented with proper position and latch-on. With placement of the nipple deep into the infant's mouth, milk transfer will be most efficient, and he should come off the breast easily when satisfied. Use of soap on the breasts should be avoided as this can cause dryness that can also lead to cracking. "When Jason has a growth spurt, he will want to nurse more often, which will increase my milk supply." --> This statement contains correct information. Babies experience predictable growth spurts. Breastfed infants need to be fed more frequently during growth spurts (7-10 days, 3 weeks, 6 weeks, 3 months). More frequent nursing predictably increases the mother's milk supply.

Following an initial prenatal visit, a woman's rubella titer results were less than 1:8. On her next visit, the woman asks what this test result means. Which is the best answer to this woman's question about her rubella titer results?

"You are susceptible to a rubella viral invasion." --> A titer of less than 1:8 suggests a woman is susceptible to viral invasion. A titer greater than 1:8 suggests immunity to the disease. A titer that is greatly increased over a previous reading or is initially extremely high suggests a recent infection has occurred.

A pregnant client presents for her first prenatal visit. She informs the nurse that she had an ectopic pregnancy 3 years ago. She ask the nurse if this would happen this time. Which response by the nurse would be best?

"Your statistical risk of another tubal pregnancy is increased."

hyperemeis gravidarum

- intractable n/v during first trimester Assessment - nausea pronounced - weight loss - signs of dehydration - fluid electrolyte imbalances Interventions - monitor for ketones - intake small portions of food - liquids should be take between meals to avoid distending the stomach and triggering vomiting - sit upright after meals

The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:

1 cm above the ischial spines

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:

1. Descent 2. flexion 3. internal rotation 4. extension 5. external rotation 6. expulsion

what is a normal BUN range?

10-20 mg/dL

what is a normal sodium range?

135-145 mEq/L

how long does a newborn typically feed on each breast?

15-20 minutes

When discussing the many changes the woman's body undergoes during pregnancy, the nurse may include that the woman's total blood volume will increase by approximately how much by the 32nd week of gestation?

1500 ml Blood volume increases by approximately 1,500 ml or 50% above nonpregnant levels by the 32nd week of gestation. This increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues.

there should be how many arteries and veins in the umbilical cord?

2 arteries, 1 vein

A client in her first trimester is concerned about how weight gain will affect her appearance and questions the nurse concerning dietary restrictions. How much weight gain should the nurse point out will be safe for this client with a low BMI?

28 to 40 pounds The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms). The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18 kilograms). Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms).

The nurse is counseling a client with a BMI of 23 about weight gain during pregnancy. The nurse teaches the client that during the second and third trimester of pregnancy, dietary intake should be increase by how many calories per day above what she was eating prior to the pregnancy?

300 extra calories per day --> A BMI of 23 is considered a healthy weight. For clients at a healthy weight, 300 additional calories are needed to support fetal growth in the second and third trimester of the pregnancy. If the client had been underweight, more calories would have been recommended; if the client had been obese, less calories would have been recommended.

normal hematocrit

36-50%

A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every: 4 weeks. 2 weeks. 3 weeks. 1 week.

4 weeks --> The recommended follow-up visit schedule is every 4 weeks up to 28 weeks, every 2 weeks from 29 to 36 weeks, and then every week from 37 weeks to birth.

what is a normal bilirubin range for a newborn?

5-6 mg/dL

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel (fontanelle) will close. Which time span is the normal duration for the closure of the posterior fontanel (fontanelle)?

8 - 12 weeks

what is the normal temp range of an infant, when should an infant be placed in a radiant warmer?

97.7° F to 99.5° F 36.5 C to 37.5 C put in warmer anything below 97.7

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply Litmus paper. Fetal scalp electrode. A sterile glove. An amnihook. Sterile vaginal speculum. Lubricant.

A sterile glove. An amnihook. Lubricant.

You perform a sterile vaginal exam and determine that Susan is 5-6 cm dilated, 100% effaced, and the fetus is at zero station. You determine that Susan is now in which phase of stage one labor? Latent phase Active phase Transition phase Expulsive phase

Active phase --> Susan completed the latent phase of stage one labor (early labor when the cervix is 0-3 cm dilated) shortly after admission. She is now in active labor. During the active phase of stage one labor, the cervix is dilated 4-7 cm, and the woman becomes more focused as contractions become more painful. Increasing apprehension is common and companionship very important. The transition phase of stage one labor occurs when the cervix is 8-10 cm dilated. In the second stage of labor, the cervix is fully dilated and the neonate is born.

In response to the order for Stadol (butorphanol tartrate), which of the following is indicated? Question the order for Stadol (butorphanol tartrate) because Susan is within one hour of delivery Question the order for Stadol (butorphanol tartrate) because the dosage is too high Administer the Stadol (butorphanol tartrate) as ordered

Administer the Stadol (butorphanol tartrate) as ordered --> It would be appropriate to administer the Stadol (butorphanol tartrate) as ordered. Susan is not expected to deliver for some time. If she were expected to deliver within an hour, Stadol (butorphanol tartrate) would not be advisable in that it could cause respiratory depression in the neonate at birth. The dosage of 1 mg is appropriate. --> Administration of Stadol (butorphanol tartrate) is appropriate since Susan is not likely to deliver for some time yet and the dosage ordered is acceptable. The progression of Susan's labor has been slow and, as a nullipara, it is likely that she will not deliver for at least a few more hours. If Susan were within one hour of delivery, Stadol (butorphanol tartrate) would not be given, as it could cause the neonate to experience respiratory depression at birth.

what is the Naegele rule? When would a client's due date be if their LMP was July 20th?

April 27th --> Naegele rule is to subtract 3 months and add 7 days from the first day of the last menstrual period to determine an expected due date, making the client's due date April 27.

What should be assessed immediately after fundus is massaged and nurse has called for help?

Assess for bladder distention --> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can contribute to diuresis. A distended bladder impedes uterine contraction and contributes to excessive bleeding. After the fundus is massaged, the bladder should be checked for distention.

During pregnancy, the cardinal rule concerning medications and herbal remedies is that all drugs cross the placenta and have a potential impact on the fetus. What is one disease where treatment must continue during pregnancy?

Asthma Other treatments for certain diseases must continue as well: epilepsy, asthma, diabetes, and depression.

An older female pregnant with her first child develops some pain in her legs associated with warmth to touch. Suspecting a blood clot, an ultrasound is prescribed and a peripheral venous thrombosis is diagnosed. Which intervention was likely prescribed for this woman?

Buy and wear medial support hose every day --> The woman should wear elastic support stockings and put them on before she arises in the morning because once she is on her feet, blood pooling begins, and the stockings will be less effective. The nurse should be certain a woman understands that the stockings she buys should be labeled "medical support hose." Otherwise, as many pantyhose manufacturers advertise their stockings as giving "firm support," she may assume erroneously this is sufficient for her. --> Blood thinners and aspirin are contraindicated in pregnancy. Because it stimulates venous return, exercise is as effective as rest periods for alleviating varicosities. Sitting at a desk for prolonged periods of time with legs bent at the knee also encourages venous stasis.

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately? Give the medication as prescribed and monitor for efficacy. Encourage the client to breastfeed rather than bottle feed. Have the client empty her bladder and massage the fundus. Call the healthcare provider to question the prescription.

Call the healthcare provider to question the prescription. --> Methergine is used to treat postpartum hemorrhage, but is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription because the client's elevated blood pressure.

Susan is talkative and does not appear to be in pain. She mentions that she has been nauseated off and on for the last 24 hours and has had little to eat or drink. She also says that she has urinated only once in the last 12 hours. Based on Susan's assessment data and history, you identify which of the following as a priority nursing diagnosis for Susan at this time? Acute Pain related to intensity of uterine contractions Fear related to loss of control during labor Urinary Retention related to pressure of uterine contractions Deficient Fluid Volume related to inadequate intake of liquids

Deficient Fluid Volume related to inadequate intake of liquids - biggest concern, and lack of urination is likely caused by lack of fluid intake

A woman in her first trimester shares with the nurse that she has been experiencing terrible nausea when she gets up in the morning. Which action should the nurse suggest? Select all that apply. Eat some saltine crackers before rising in the morning. Suck on sour candies. Delay breakfast until 10 or 11 AM. Try eating a snack before bedtime Eat two regular meals later in the day. Use a scopolamine patch.

Eat some saltine crackers before rising in the morning. Suck on sour candies. Delay breakfast until 10 or 11 AM. Try eating a snack before bedtime

T/F Braxton Hicks contractions help in bringing about oxytocin sensitivity.

False

A client at 28 weeks' gestation is asking for a laxative for constipation. What action would the nurse recommend?

Fiber rich foods --> Laxatives, suppositories, and enemas only provide temporary relief and may stimulate labor.

A pregnant client at 18 weeks' gestation has arrived for her routine prenatal visit. Which assessment findings should the nurse prepare to document at this time? Select all that apply. Fundal height of approximately 18 cm Quickening Insomnia Braxton Hicks contractions Leg cramps

Fundal height of approximately 18 cm Quickening

A pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records?

G: 3 T: 0 P: 1 A:1 L:2

Griffie's fetal HR: HESI fetal HR: Peds infant HR:

Griffie's fetal HR: 120 - 160 HESI fetal HR: 110 - 160 Peds infant HR: 100 - 160

The nurse is assessing the external fetal monitor and notes the following: fetal heart rate of 175 beats/min, decrease in variability, and late decelerations. Which action should the nurse tale first?

Have the client change position. Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the client to change position to see if that will take the pressure off the cord. The health care provider should be notified, especially if a change of position is ineffective. The nurse should continue to monitor the pattern continuously until the situation is changed and to evaluate the effectiveness of interventions. This could be an ominous sign indicating the need for further interventions to include cesarean birth.

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

Hyperstimulation.

A nurse is teaching a client who is 30 weeks' pregnant about ways to deal with pyrosis (heartburn). The nurse determines a need for additional teaching based on which client statement?

I should lie down a half hour after eating

Which of the following information should be communicated to Susan regarding the benefits of smoking cessation at this point in her pregnancy?

It will decrease the risk of intrauterine growth restriction (IUGR) and giving birth to a low-birth-weight infant It will increase the oxygen supply to the fetus It will reduce the risk of preterm labor and premature rupture of membranes WILL NOT reduce risk of neural tube defects

Susan has decided to rest in bed for a while. Which of the following positions are acceptable? Select all that apply Left lateral Supine Prone Right lateral

Left lateral and right lateral are acceptable why not supine? --> In the supine position, the gravid uterus compresses the mother's aorta and inferior vena cava. This can result in maternal hypotension with subsequent diminished placental perfusion and fetal hypoxia (vena cava syndrome). The supine position should, therefore, not be used by the laboring woman.

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? decreased sedation less anxiety increases progress of labor

Less anxiety Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.

At the next assessment, Susan's uterus is midline. The fundus feels boggy at one fingerbreadth below the umbilicus. What should you do first?

Massage Susan's uterus

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes.

Maternal and fetal heart rates. --> Terbutaline has effects on receptors. It acts as a sympathomimetic agent stimulating beta 1 receptors which cause tachycardia as a side effect and that is a reason why monitoring maternal and fetal heart rates is most important when terbutaline is being administered. It also affects beta 2 receptors which relaxes the uterus and that is the reason for its administration.

A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: Occurring every 5 minutes Lasting for 30 seconds Occurring in the abdomen and groin area Relieved by walking

Occurring every 5 minutes --> The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?

On the uterine fundus

The multigravida client is in the late active phase of labor and asks for an opioid, stating they do not remember the pain being this bad in previous births. Which response from the nurse is best?

Pain medication can affect the baby's breathing; let's try to focus and breathe." Once the client has entered into the later active phase of labor, the client is considered to be imminent for birth. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise in the newborn. The nurse will encourage nonpharmacologic methods at this point and should not consult the health care provider. The nurse should also remain supportive of the client in labor.

A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV magnesium sulfate after being diagnosed with severe preeclampsia. After determining the serum magnesium level to be 15 mEq/L, the nurse should expect which of the following manifestations in the client? ECG changes. Loss of reflexes. Respiratory distress. Cardiac arrest.

Respiratory distress --> The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG changes occur at 5 to 10 mEq/L. Loss of reflexes is unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client may experience respiratory distress. At 25 mEq/L, cardiac arrest may occur.

Which response by the student indicates an understanding of the purpose for administering vitamin K? The purpose of this drug is to prevent hypoglycemia in the newborn. Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status. This drug is given to the newborn to prevent and/or treat hemorrhagic disease. Vitamin K is produced and stored in the liver, which is immature in the infant.

This drug is given to the newborn to prevent and/or treat hemorrhagic disease. --> Because this vitamin does not cross the placenta and there is very little in breast milk, supplemental vitamin K should be given to newborns at birth to help clot the blood. Therefore, this is an accurate response by the student and no further client teaching is needed --> vitamin K does not prevent hypoglycemia. --> positive nutritional status is not the primary reason for giving vitamin K --> Vitamin K is produced in the gut but not stored in the liver.

A nurse is caring for a pregnant client in her second trimester of pregnancy. The nurse educates the client to look for which danger sign of pregnancy needing immediate attention by the primary care provider?

Vaginal bleeding --> Generally, painful urination, severe/persistent vomiting, and lower abdominal and shoulder pain are the danger signs that the client has to monitor for during the first trimester of pregnancy, and NOT the second trimester

The nurse is caring for a client who is having a high-risk pregnancy and requires genetic studies. Which procedures will the nurse anticipate? Select all that apply. a. Amniocentesis b. Maternal serum alpha-fetoprotein screening c. Chorionic villus sampling d. Percutaneous umbilical blood sampling e. Ultrasonography

a. amniocentesis c. Chorionic villus sampling d. Percutaneous umbilical blood sampling

Susan mentions, "I've heard that it is normal to be a little anemic during pregnancy." You understand that Susan is probably referring to the "physiologic anemia of pregnancy." This is related to:

an increase in plasma volume in excess of an increase in red blood cells --> During pregnancy, Susan's plasma volume will increase by 50%, but her red blood cells will increase only by 18-30%, depending on whether or not she takes iron supplements. This results in hemodilution, with a corresponding decrease in normal hemoglobin and hematocrit values. This is often referred to as the "physiologic anemia of pregnancy" or the "hemodilution of pregnancy."

what is considered an abortion?

any loss of pregnancy prior to 20 weeks gestation, after it is considered preterm delivery without a tally for living

The nurse performs the first assessment upon the client's arrival to the postpartum unit. Where would the nurse expect to palpate the fundus? a. 3 cm above the umbilicus. b. 1 cm above the umbilicus. c. To the right of the umbilicus. d. Midway between the umbilicus and the pubic bone.

b. 1 cm above the umbilicus. For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus

Which instructions should the nurse include in the discharge planning regarding the infant's jaundice? a. The phototherapy blanket is placed over the infant's clothing. b. Holding the infant does not interrupt the phototherapy process. c. A phototherapy blanket is more effective than the overhead lights. d. The length of time required for phototherapy intervention is decreased.

b. Holding the infant does not interrupt the phototherapy process. --> Although diapers can be worn, the blanket is placed next to the skin on the trunk of the body to expose as much skin as possible to the light. --> The phototherapy blanket allows the infant to be held while the process is continued.

Fifteen minutes after the initial assessment, the nurse finds the client disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood. Which action is most important for the nurse to implement immediately? a. Take vital signs b. Massage the fundus c. Check the bladder d. Increase the IV rate

b. Massage the fundus. Since a boggy fundus is the most likely reason for this client's hemorrhaging, massing the fundus is the most important intervention. The nurse should also call for assistance due to the amount of blood that has pooled under the client.

what is fetal tachycardia defined as?

baseline FHR above 160 bpm for more than 10 minutes

what is fetal bradycardia defined as?

baseline FHR less than 110 bpm, and lasting more than 10 minutes

A pregnant client is being discharged from the labor and birth suite because of false labor. The client asks the nurse how to tell whether the contractions are true contractions or Braxton Hicks contractions. Which description(s) will the nurse mention as characteristic of true contractions? Select all that apply. begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity begin and remain irregular felt first abdominally and remain confined to the abdomen and groin often disappear with ambulation or sleep

begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity

When John describes to you the advantages he sees in breastfeeding, you agree when he says: Select all that apply breastfed babies sleep better breastfed babies are not likely to have allergies to their mother's breast milk breastfeeding is more economical breastfed babies experience fewer respiratory illnesses than formula-fed babies

breastfed babies are not likely to have allergies to their mother's breast milk breastfeeding is more economical breastfed babies experience fewer respiratory illnesses than formula-fed babies

A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting?

buttocks (s = sacrum)

The infant has a reddish papular rash across his face. How should the nurse respond when the client asks about the rash? a. Don't worry about it. This rash will go away in a couple of days. b. I see you are concerned, so I will call your pediatrician. c. A newborn rash is very common, but it will disappear soon. d. Good question. Let me take the infant's vital signs and examine him

c. A newborn rash is very common, but it will disappear soon. --> The infant rash, erythema toxicum, is very common and usually disappears by the third day of life.

When the nurse conducts a gestational age assessment, which findings may indicate postmaturity? (Select all that apply. One, some, or all options may be correct.) a. Testes descended, good rugae. b. Formed ears with instant recall. c. Peeling, parchment-like skin. d. Thin with loose skin and little subcutaneous fat. e. Deep creases at the base of the toes extending to the heels.

c. d. and e. c. Peeling, parchment-like skin. d. Thin with loose skin and little subcutaneous fat. --> Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This results in the infant's low temperature. e. Deep creases at the base of the toes extending to the heels. --> Postterm infants develop deep creases on the feet, extending from the base

While examining the infant's head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. What should the nurse do, what does this indicate?

caput succedeum, document finding in record

You perform a vaginal exam to check for shortening and thinning of Susan's cervix. This is called _______________

effacement

Prostaglandin levels increase late in pregnancy secondary to elevated ___________________ levels

estrogen

what are possible causes of fetal bradycardia?

fetal hypoxia, maternal hypothyroidism or hypotension, or drug effects (anesthesia)

The anesthesiologist performs the epidural procedure and Susan begins to feel almost immediate relief from painful contractions. You know that a priority nursing intervention is to: keep Susan in a reverse Trendelenburg position to promote spread of the epidural anesthetic frequently monitor Susan's blood pressure for hypotension be alert for hypertensive crisis keep Susan in the supine position to prevent postspinal headache

frequently monitor Susan's blood pressure for hypotension

what can tachycardia also be an early sign of in fetus's?

hypoxia

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. increase in heart rate increase in blood pressure increase in respiratory rate slight decrease in body temperature increase in gastric emptying and pH

increase in heart rate increase in blood pressure increase in respiratory rate When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in systolic blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

You remind Susan that it is important for her to try to urinate every two hours. The rationale for this is that a distended bladder can: Select all that apply increase the pain associated with uterine contractions cause difficulty in voiding after delivery interfere with fetal descent increase the risk of bladder rupture during long contractions

increase the pain associated with uterine contractions cause difficulty in voiding after delivery interfere with fetal descent --> bladder rupture is not likely

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increased WBC

when labor is imminent, estrogen _______________, progesterone _________________, and oxytocin _________________

increases; decreases; increases

what does variability indicate?

intactness of the fetal neurologic system, fetal oxygenation, and fetal oxygen reserve

You go on to assess the condition of Susan's uterus. The term that describes the expected gradual reduction in size of the uterus after delivery as it contracts to return to normal size is __________________

involution

Occurrence of _____________________, not Braxton Hicks contractions, makes maternal breathing easier.

lightening

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. lightening weight gain constipation bloody show backache

lightening bloody show backache

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

Which vaccines are contraindicated during pregnancy since they may transmit a viral infection to the fetus? Select all that apply. measles mumps influenza rubella Tdap vaccine (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis)

measles mumps rubella

A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response?

measurement to see if pelvis is adequate for vaginal delivery

A pregnant woman has been diagnosed with pica since she eats lead paint chips for their sweetness. The nurse educating this woman should strongly encourage her to abandon this practice because it may have which consequence to the fetus?

neurological changes --> Lead ingestion during pregnancy may lead to a newborn who is both cognitively and neurologically challenged.

John asks, "Why does he need to have a shot already?" Your explanation to John is based on the knowledge that: Select all that apply newborns are unable to synthesize vitamin K due to absence of intestinal flora at birth vitamin K is necessary to prevent the occurrence of physiologic jaundice in newborns vitamin K provides protection from infection during the first week after birth vitamin K is needed to prevent bleeding problems in the early neonatal period

newborns are unable to synthesize vitamin K due to absence of intestinal flora at birth --> The gut of the newborn infant is sterile at birth and remains so until feeding is begun. Due to the absence of intestinal flora, newborns are unable to synthesize vitamin K. Levels of vitamin K rise after the first week to reach adult levels by the age of nine months. vitamin K is needed to prevent bleeding problems in the early neonatal period --> Vitamin K activates coagulation factors that are synthesized by the liver. In the absence of vitamin K at birth, the infant is predisposed to bleeding problems. Vitamin K provides prophylaxis against hemorrhagic disease of the newborn.

You also know that when an infant suckles at the breast, the milk ejection or let-down reflex is stimulated to allow milk to fill the lactiferous sinuses just behind the nipple. The hormone responsible for milk ejection is

oxytocin

The five "Ps" of labor are: passenger, position, powers, presentation, psych. passenger, posture, position, presentation, psych. passenger, position, presentation, pushing, psych. passageway, passenger, position, powers, psych.

passageway, passenger, position, powers, psych. --> The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response)

A nurse is caring for a 20-year-old primigravida client who is at 18 weeks' gestation. The client had been experiencing occasional nausea and vomiting in the morning and now reports persistent nausea and vomiting in the past 48 hours. Client has lost 3 lb (1.36 kg) in 2 days. The nurse performs a comprehensive assessment on the client. Vital signs: heart rate, 110 beats/minblood pressure, 88/56 mm Hg. Laboratory values: blood urea nitrogen (BUN), 25 mg/dl (8.93 mmol/l) and sodium 148 mEq/l (148 mmol/l). What is concerning in this excerpt?

persistent N/V is a sign of Hyperemesis gravidarum in first trimester --> Hyperemesis gravidarum is persistent nausea and vomiting with weight loss due to inability to ingest food or fluid, which leads to dehydration. A 3-lb (1.36-kg) weight loss in 2 days due to persistent nausea and vomiting is an indication the client is experiencing hyperemesis gravidarum. The weight loss is due to the client's inability to ingest food or fluids, which leads to severe dehydration and malnutrition. The nurse should request intravenous fluids. A blood urea nitrogen (BUN) level of 25 mg/dl (8.9 mmol/l) (normal: 8 to 20 mg/dl; 2.9 to 7.5 mmol/l) is an indication that the client is dehydrated.A serum sodium level of 148 mEq/l (148 mmol/l) (normal: 135 to 145 mEq/l; 135 to 145 mmol/l) is an indication that the client is dehydrated. A blood pressure of 88/56 mm Hg may be an indication of dehydration. A heart rate of 110 beats/min is a compensatory mechanism due to the low blood pressure.

Because Susan had an epidural she has not exhibited some of the signs/behaviors that otherwise characterize the transition phase. These include: Select all that apply lethargy physical shaking reluctance to be touched amnesia between contractions diaphoresis

physical shaking reluctance to be touched amnesia between contractions diaphoresis

After delivery, a declining level of estrogen allows for rising levels of the hormone responsible for milk production. You know that the hormone that stimulates milk production is

prolactin

You then apply erythromycin ophthalmic ointment to the newborn's eyes to: alleviate the conjunctivitis that is common to all newborn infants protect the infant from gonorrheal or chlamydial infection

protect the infant from gonorrheal or chlamydial infection --> All newborns in the United States receive eye prophylaxis at birth to protect against opthalmia neonatorum, eye inflammation caused by gonorrheal or chlamydial infection. Prophylaxis is provided whether or not the mother is known to have these infections.

What can cause the onset of labor? increase in the production of progesterone fall in the estrogen at 34 to 35 weeks of pregnancy decrease in the fetal cortisol levels release of oxytocin by the pituitary prostaglandin production in the myometrium

release of oxytocin by the pituitary prostaglandin production in the myometrium --> The possible causes for the onset of labor include an increase in the fetal cortisol levels, release of oxytocin by the posterior pituitary, and the production of prostaglandins. Progesterone withdrawal, and not an increase, initiates labor. There is a rise in the estrogen levels at 34 to 35 weeks' of pregnancy. Estrogen stimulates prostaglandin production and also promotes the release of oxytocin.

infant has occiput presentation, Based on your assessment, you position the ultrasound transducer on Susan's abdomen at the:

right lower quadrant

How do Braxton Hicks contractions assist in labor? They also help by moving the cervix from a _______________ position to an ________________ position.

ripening and softening the cervix posterior --> anterior

A client in latent labor for the past 12 hours is requesting medication to help her rest. The nurse predicts the health care provider will prescribe which medication? meperidine secobarbital fentanyl morphine

secobarbital In the latent phase of labor, sedatives can be prescribed to assist a client to rest. The use of analgesics, such as opioids (meperidine, fentanyl, and morphine) in early labor may stop labor and are not recommended.

After the placenta has been expelled, Dr. Cooper asks you to start a Pitocin (oxytocin) drip, at a concentration of 10 units in 1000 mL Lactated Ringer's. You know that Pitocin (oxytocin) is administered at this time to:

stimulate uterine contractions --> Pitocin (oxytocin) is a synthetic form of oxytocin, a hormone that causes intermittent uterine contractions with retraction of myometrial strands. It is given after delivery of the fetus and the placenta to prevent uterine atony and postpartum hemorrhage. Dose is titrated to achieve adequate uterine contraction. Use of Pitocin (oxytocin) is protocol in some institutions, or may be provider preference.

You also determine that the fetus is at zero station. John is curious about what you mean by "the fetus is at zero station." Your response is based on the knowledge that zero station means that: the baby's presenting part is at the level of the mother's ischial spines the baby's presenting part is at the level of the mother's pelvic inlet the biparietal diameter of the fetal skull is at the level of the mother's iliac crests the baby's head is high in the pelvis and is still ballottable

the baby's presenting part is at the level of the mother's ischial spines --> When the fetus is considered to be at zero station, the presenting part is at the level of the mother's ischial spines. The presenting part is now "engaged."

what does variability indirectly indicate?

the infant's ability to withstand labor

Fetal heart rate increases can be associated with a variety of factors. These include: the mother receiving the drug Brethine (terbutaline) maternal hypotension The mother receiving the drug Yutopar (ritodrine) Maternal fever or infection Fetal anemia

the mother receiving the drug Brethine (terbutaline) The mother receiving the drug Yutopar (ritodrine) Maternal fever or infection Fetal anemia --> Also: - Maternal Dehydration - Maternal Hyperthyroidism NOT maternal hypotension - this would usually lead to fetal bradycardia, not tachycardia

A woman's perception of pain can differ according to all of the following except:

the presentation, lie, and attitude of the fetus

Which factor should alert the nurse to assess for the risk of jaundice?

trauma at birth

In response to the occurrence of a late deceleration, which of the following actions should be carried out FIRST?

turn Susan on her left side

what is the most likely reason a postpartum patient would be hemorrhaging?

uterine atony (a "boggy" fundus)

what is the most important aspect of the FHR?

variability

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.