Maternity: Pregnancy, Labor, Childbirth, Postpartum - At Risk, Uncomplicated; Nursing Care of the Newborn

The fetus of a client in labor is found to be at +1 station. Where did the nurse locate the fetus's head?

Just below the ischial spines Rationale: The term station is used to indicate the location of the presenting part. The level of the tip of the ischial spines is considered zero station. The position of the bony prominence of the fetal head is described in centimeters, minus (above the spines) or plus (below the spines). On the perineum, referred to as crowning, is designated as +5. High in the pelvis is indicated by the term floating, which means that the presenting part has not yet engaged in the pelvis. A station of -1 indicates that the head is just above the ischial spines.

A nurse is caring for a client who has severe preeclampsia. For which characteristic of eclampsia should the nurse monitor the client?

Seizures Rationale: Seizures are the unique characteristic sign of eclampsia that occurs because of central nervous system irritation. Anasarca (generalized edema) is a sign of severe preeclampsia. Excessive weight gain is a sign of preeclampsia. Increased blood pressure is a sign of preeclampsia.

What should a nurse anticipate about the insulin requirements of a client with diabetes on her first postpartum day?

A sharp, sudden decrease Rationale: Insulin requirements may fall suddenly during the first 24 to 48 postpartum hours because the endocrine changes of pregnancy are reversed. Insulin requirements do not suddenly increase, remain unchanged, or decrease slowly and steadily at this time.

When checking the cervical dilation of a client in labor, a nurse notes that the umbilical cord has prolapsed. What is the priority nursing action?

Assisting the client into the Trendelenburg position Rationale: Placing the client in the Trendelenburg position may prevent further prolapse and should relieve pressure on the umbilical cord. Taking the fetal heart rate will be done later; the priority is relieving pressure on the umbilical cord. Turning the client on her side will not relieve pressure on the umbilical cord, although it will promote placental perfusion. Covering the cord with a sterile saline-soaked cloth will not relieve pressure on the umbilical cord.

A client is bleeding excessively after the birth of a neonate. The health care provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin (Pitocin) at a rate of 100 mL/hr. A nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action?

Checking for a distended bladder Rationale: A displaced and boggy uterus is usually caused by a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus and, if still boggy, massage until it is firm. The oxytocin (Pitocin) infusion may need to be increased if voiding and fundal massage are ineffective; however, the health care provider must be notified to change the prescription. Continuing to perform fundal massage is necessary if the fundus remains boggy after the client has voided. Continuing to assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the priority.

A client in her 37th week of gestation calls a nurse in the prenatal clinic and reports, "My ankles are swollen." What should the nurse recommend?

Elevating her legs more frequently during the day Rationale: Dependent edema in the ankles is a common occurrence during the latter part of pregnancy. It results from increased pressure of the uterus on the pelvic veins. Elevating the legs encourages venous return. Limiting fluid intake can be harmful; increased circulating blood volume during pregnancy must be maintained. Salt is necessary to retain fluid for the increased circulating blood volume during pregnancy. Diuretics are not used during pregnancy; they may decrease the circulating blood volume.

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to:

Estimate fetal age Rationale: Measurement of the crown-rump length (CRL) is useful in approximating fetal age in the first trimester. Hydrocephalus cannot be detected during the first trimester. Ultrasonography is used to detect structural defects in the second trimester. It is too early in this pregnancy to determine fetal linear growth.

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains?

Multipara who has vaginally delivered three children Rationale: A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.

A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief?

"Eat dry crackers before you get out of bed." Rationale: Nausea and vomiting in the morning occur in almost 50% of all pregnancies. Eating dry crackers before getting out of bed in the morning is a simple remedy that may provide relief. Increasing fat intake does not relieve the nausea. Drinking high-carbohydrate fluids with meals is not helpful; separating fluids from solids at mealtime is more advisable. Eating two small meals a day and a snack at noon does not meet the nutritional needs of a pregnant woman, nor will it relieve nausea. Some women find that eating five or six small meals daily instead of three large ones is helpful.

What should a nurse suggest to a pregnant client that might help overcome first-trimester morning sickness?

"Eat protein before bedtime." Rationale: Nausea and vomiting in early pregnancy can be relieved with a small snack of protein before bedtime to slow digestion. An antacid may affect electrolyte balance, and it will not ease morning sickness. Drinking water until the nausea subsides is contraindicated, because both fetus and mother need nourishment. Many medications and herbal remedies in the first trimester are contraindicated because this is the period of organogenesis, and such preparations could have teratogenic effects.

A primigravida at 36 weeks' gestation is admitted to the birthing room with ruptured membranes and a cervix that is dilated 2 cm and 75% effaced. What is the priority question the nurse should ask?

"How frequent are your contractions?" Rationale: The priority is to assess the progression of labor so the nurse can plan care. The client should also be asked when her expected date of birth is, how she plans to manage her labor, and when she ate her last meal, but these questions are not the priority.

During a prenatal visit a client who is at 36 weeks' gestation states that she is having uncomfortable irregular contractions. How should the nurse respond?

"Walk around until they subside." Rationale: Ambulation relieves the discomfort of preparatory (Braxton Hicks) contractions. These contractions will increase when the client is resting. Preparatory contractions are not indicative of true labor and need not be timed. Aspirin may be harmful to the fetus because it can hemolyze red blood cells.

What should a nurse include in nutritional planning for a newly pregnant woman of average height who weighs145 lb?

An increase of 300 calories per day Rationale: An increase of 300 calories per day is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy. A decrease of 100 to 200 calories per day will not meet the metabolic demands of pregnancy and may harm the fetus. An increase of 500 calories per day is the recommended caloric increase for breastfeeding mothers.

A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient?

Audible fetal heartbeat Rationale: The presence of the fetal heartbeat is a positive sign of pregnancy. The feeling of movement is a presumptive sign of pregnancy. An enlarged abdomen is a probable sign of pregnancy. The bluish color of the cervix (Chadwick's sign) is caused by pelvic congestion and edema; it is a probable sign of pregnancy.

During a physical in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. What sign should the nurse document in the client's clinical record?

Chadwick Rationale: A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton Hicks contractions, can be felt through the abdominal wall.

The nurse is caring for a client in transitioning labor and notes an early deceleration on the fetal heart monitor. Which intervention would be appropriate for the nurse to implement?

Continuing to monitor fetal heart rate (FHR) tracing Rationale: Early fetal heart rate (FHR) decelerations, with onset before the peak of the contraction and low point at the peak of the contraction, are due to fetal head compression. This is a normal finding during the transition stage of labor as the head descends.

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?

Document the stool in the infant's record. Rationale: The neonate's first stool, which is thick and greenish-black, is called meconium; the appearance of meconium is an expected occurrence that should be documented. This stool is expected; there is no reason to suspect intestinal obstruction. Meconium stool on the first day of life is expected and does not require further examination. Meconium is not indicative of bleeding; it contains bile and other waste products produced by the fetus. Passage of meconium does not require notification of the practitioner.

A nurse is reviewing a client's history. What two predisposing causes of puerperal (postpartum) infection should prompt the nurse to monitor this client closely?

Hemorrhage and trauma during labor Rationale: Blood loss depletes the cellular response to infection; trauma provides an excellent avenue for bacteria to enter. These issues may create problems if hemorrhage occurs because the hemoglobin and hematocrit are already low. Preeclampsia is not a predisposing factor in postpartum infection; retained placental fragments cause hemorrhage and if not removed immediately will result in hypovolemic shock, not infection. Endogenous infections are rare; infection is usually caused by outside contamination. Trauma and the denuded placental site may contribute to the development of infection.

A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn?

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

Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem?

Injury to brachial plexus during birth Rationale: Erb's palsy is caused by forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus. Erb's palsy is not acquired in utero. Erb's palsy is not caused by an X-linked inherited disease. Erb's palsy is not caused by a tumor.

A client with preeclampsia is to receive a magnesium sulfate infusion, and the nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply.

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

A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight?

Perform serial glucose readings. Rationale: A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia because maternal glucose is no longer available. The nurse should do more than document the findings; the health care provider should be notified after the serial glucose readings are taken. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth. The infant may be hypoglycemic and require the glucose in an oral feeding immediately.

When palpating a client's fundus on the second postpartum day, a nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude?

The bladder has become overdistended. Rationale: A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contraction and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment about overstretched uterine ligaments.

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted?

This threat is considered assault, and the nurse should not have reacted in this manner. Rationale: This response is a threat (assault) because the nurse is attempting to put pressure on the client to speak or be left alone. This is not a reward and punishment technique that is used in behavior modification therapy. Clients in emotional crisis should not be left alone.

When a client's legs are being placed in stirrups for birth, the nurse ensures that the left and right legs are positioned simultaneously to help prevent:

Trauma to the uterine ligaments Rationale: As the uterus rises into the abdominal cavity, the uterine ligaments become elongated and hypertrophied; raising both legs at the same time limits the tension placed on these ligaments. Lifting the legs simultaneously does not affect circulation in the legs. Pressure is already being exerted on the perineum by the head of the fetus; this maneuver eases tension on the uterine ligaments. This maneuver has no effect on the fascia.

Which newborn assessment finding will probably necessitate prolonged follow-up care?

Umbilical cord with two blood vessels Rationale: The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies. There should be two arteries and one vein. It is too soon to determine whether the newborn needs prolonged follow-up care; this conclusion is based on the second Apgar score, 5 minutes later. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL.

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb at birth. Which finding should be reported immediately to the health care provider?

Weight of 6 lb 4 oz Rationale: A loss of 12 oz since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL, total serum bilirubin of 10 mg/dL, and three wet diapers over the last 12 hours are all normal and expected findings.

A client in active labor is admitted to the birthing unit. It is determined that the fetus is in the right sacrum anterior (RSA) position/presentation. Judging from the illustration, what is the point of maximal intensity for monitoring of fetal heart tones?

a Rationale: When the fetus is in a breech (sacrum and feet) presentation, fetal heart tones are heard above the umbilicus. With a right anterior position, the back is on the maternal right side. Option 2 is the location in which to place the ultrasound transducer when the fetus is in the left sacrum anterior (LSA) presentation/position. Option 3 is the location at which to place the ultrasound transducer when the fetus is in the right occipitoposterior (ROP) presentation/position. Option 4 is the location at which to place the ultrasound transducer when the fetus is in the left occipitoposterior (LOP) presentation/position.

A nurse is assessing a new client in active labor for fetal position. Where will fetal heart tones best be heard if the fetus' position is LOA?

d Rationale: In the most common position, left occiput anterior, the fetus's back is on the left side of the mother, in the left occiput anterior position. Position a is correct when the fetus is in the right sacrum anterior position. Position b is correct when the fetus is in the right occiput posterior position. Position c is correct when the fetus is in the left sacrum anterior position.