N201 OB: Pregnancy, Labor, Childbirth, Postpartum- Uncomplicated
A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of what?
7.5
A client at 8 weeks' gestation tells the nurse that since becoming pregnant, she has not felt like making love with her husband. She is concerned that her husband does not understand. What is the most appropriate response by the nurse?
A decrease in libido is common during the first trimester of pregnancy."
A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of this pregnancy?
Accept that she is pregnant
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question?
Accompanied by progressive cervical dilation
While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats per minute that lasts 15 seconds. How should the nurse document this event?
An acceleration
A client who expected to use the Lamaze technique throughout labor has an emergency cesarean birth. Two days later the client is found crying and tells the nurse that she is extremely disappointed because a cesarean birth was necessary. She asks the nurse why this happened to her. The nurse answers based upon which physiologic response?
An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience
What should a nurse include in nutritional planning for a newly pregnant woman of average height who weighs 145 lb (65.8 kg)?
An increase of 300 calories per day [An increase of 300 calories per day is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy.]
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client?
Anticipating safety needs by instructing the client to remain in bed and call for assistance whenever ambulating
After a client gives birth, which physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?
Appearance of a sudden gush of blood
A pregnant woman is admitted in active labor. What should the nurse instruct her coach to do when the client complains of back pain?
Apply pressure to the sacrum during contractions.
What is the optimal nursing intervention to minimize perineal edema after an episiotomy?
Applying icepacks [causes vasoconstriction]
A client tells the nurse that the first day of her last menstrual period was July 22. What is the estimated date of birth (EDB)?
April 29th
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action?
Asking the client when she last changed the perineal pad
The clinic nurse is reviewing the dietary intake of a 16-year-old client who is 12 weeks pregnant. What is the nurse's most appropriate action in this circumstance?
Asking the client, "How many servings of dairy do you generally consume each day?"
A laboring client experiences a spontaneous rupture of membranes. What is the nurse's priority?
Assess fetal heart rate
While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next?
Assess the fetal heart rate [reflects how well the fetus tolerates the membrane]
A client at 40 weeks' gestation is admitted to the birthing unit, and an amniotomy is performed to facilitate labor. Once the nurse determines that the umbilical cord has not prolapsed, what is her next action? Correct 1
Assessing the fetal heart rate
The 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. Which positive sign of pregnancy should the nurse evaluate in this client?
Audible fetal heart beat [is a positive sign of pregnancy]
A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and dilated 3 cm. The fetal head is at +1 station. In which area of the client's pelvis is the fetal occiput?
Below the ischial spines [A station of +1 indicates that the fetal head is 1 cm below the ischial spines. The head is now past the points of engagement, the ischial spines. When the head is entering the pelvic inlet, it is said to be at 0 station. The head must be at +3 to +4 station to be visible at the vaginal opening]
After performing Leopold maneuvers on a laboring client, the nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones?
Below the umbilicus on the right side
A client whose membranes have ruptured is admitted to the birthing unit. Her cervix is dilated 3 cm and 50% effaced. The amniotic fluid is clear, and the fetal heart rate is stable. Which outcome does the nurse anticipate?
Birth of the fetus within a day
A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" What information about adolescent growth and development does the nurse need to understand before responding?
Body image is very important to adolescents; therefore pregnant teenagers are overly concerned about body size
During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?
Breathe into her cupped hands
During an emergency birth the fetal head is crowning on the perineum. How should the nurse support the head as it is being delivered?
By distributing the fingers around the head [prevent rapid change in ICP]
The client who is pregnant for the first time asks the nurse about the changes in her body. While describing the changes in each body system, the nurse mentions that the system that undergoes the most profound change of all during pregnancy is the what?
Cardiovascular [Total blood volume increases by 50%, making it necessary for the heart to pump harder and work more to accommodate this increase]
How does the nurse determine when true labor and not false labor is present?
Cervical dilation is evident.
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next?
Changing the client's position
A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The 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 [if uterus is boggy after fundal massage the bladder can be distended]
During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat?
Cheese and broccoli
A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions do what?
Come every 5 minutes for an hour
A nurse is teaching a childbirth preparation class. Which information regarding discomfort during labor should the nurse be certain to include in her teaching?
Comfort measures are available when the discomfort of contractions becomes excessive.
A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by what?
Compression by the enlarging uterus
External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?
Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends
Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?
Different cultural groups favor different essential nutrients
A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take?
Discontinuing the test because the pattern is within the normal range
A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments?
Document the results because they are expected at 20-weeks' gestation
A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with what?
Doppler ultrasound 10-12 weeks
The nurse is caring for a client in transitioning labor and notes an early deceleration on the fetal heart monitor. Which nursing intervention would be most appropriate at this time?
Early 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
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 in the morning
The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment?
Empty her bladder
Which instruction is most important for the nurse to include when teaching a client about a contraction stress test (CST)?
Empty the bladder before the test
A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement?
Encourage the family to bring in special foods preferred in their culture.
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?
Enlarging area of caput with each contraction
A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?
Explain why this is expected in early pregnancy
The nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor has this client reached?
First
Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks.
G4, T1, P1, A1, L
While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?
G5 T1 P1 A2 L2
When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action should the nurse implement at this time?
Having her pant blow during contractions
In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time?
Having the client empty her bladder [a full bladder elevates the uterus and places it to the right]
A client who has been breastfeeding tells the nurse on the third postpartum day that her breasts are painful and that she is afraid that the baby will hurt her while grasping the nipple and suckling. How should the nurse respond at this time?
Helping the client express some milk manually before feeding [the pressure and tenderness is because of accumulated milk, releasing some milk will ease tension]
A client who is at 12 weeks' gestation tells the nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. Which factor is frequently associated with this disorder?
High level of chorionic gonadotropin
A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram?
Increase fluid intake for 1 hour before the procedure [The bladder must be full, not empty, for better visualization of the uterus]
Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion?
Increased bloody show, irritability, and shaking
While experiencing contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse's priority intervention be at this time?
Inspect the client's perineum for bulging.
The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day?
Instructing the client to add calories while continuing to eat a healthy die
Upon arriving in the birthing room the nurse finds the client lying on her back with her head on a pillow and the bed in a flat position. The nurse explains that it is important to avoid lying in the supine position because of what reason?
It will prevent adequate blood flow to the fetus
A nurse performs Leopold maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is what?
LOA
A pregnant client at 37 weeks' gestation is taught the signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report what?
Leakage of fluid from the vagina
A woman at 40 weeks' gestation is admitted in active labor. When the client reaches 5 centimeters dilation, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which assessments and interventions should be performed? Select all that apply.
Maintaining IV fluid administration Having oxygen available incase of hypotension Checking bladder for distention q2h Monitoring fhr and labor per hospital protocol
What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline?
Massaging the uterine fundus
During a childbirth class the nurse determines that the women understand how to use effleurage correctly when they are observed doing what?
Massaging their abdomens gently with their fingertips
A vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior (ROA) position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor?
Midway through first stage of labor
The nurse is assigned to care for an adolescent who gave birth 12 hours ago. The client continually talks on the phone to her friends and does not respond when her new baby cries. What is the priority intervention at this time?
Modeling appropriate behaviors that encourage infant bonding
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?
Moderate rubra
The nurse considers the pros and cons of external fetal monitoring versus internal fetal monitoring. What is one advantage of the external fetal monitor?
No risk of infection
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action?
Notify the health care provider supposed to be higher than 110 bpm
The nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?
One fingerbreadth above the umbilicus
A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. Which breathing pattern should the nurse instruct the client to adopt?
Pant and then exhale through the mouth with pursed lips
The nurse is caring for a client in the transition phase of labor. Which breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation?
Panting blowing
A client is admitted to the birthing room in active labor. She is gravida 4, para 3. When she is at 8 cm of dilation, her membranes rupture spontaneously. What should the nurse do after assessing fetal well-being?
Perform a vaginal exam.
A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response?
Peripheral vasomotor activity is promoted.
The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day?
Pinkish brown
Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client's plan of care include?
Placing the client in the semi-Fowler position to increase cervical pressure [Placing the client in the semi-Fowler position forces the heavy uterus to put pressure on the blood vessels at the site of the separating placenta, controlling bleeding to some extent]
A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed?
Progressive dilation and effacement
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?
Provide the client with comfort measures used for women in labor.
On a routine prenatal visit, what is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time?
Quickening [recognition of fetal movement 18-20 weeks]
While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse's most appropriate action at his time?
Record the fetal response to contractions and continue to monitor the heart rate.
The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first?
Reposition her on the left side
Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration.
Repositioning the client from side to side
The nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client?
Semi-Fowler position to avoid hypotension
The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of most concern to the nurse?
Spontaneous rupture of membranes 3 hours ago
The electronic fetal monitor displays contractions every 2 minutes and lasting 95 seconds. What is the nurse's highest priority intervention at this time?
Stop the oxytocin (Pitocin) infusion.
A client in active labor is admitted to the birthing room. A vaginal examination reveals the cervix to be dilated to 7 cm. On the basis of this finding, what does the nurse expect the client to exhibit?
Strong contractions several minutes apart
Which position does the nurse teach the client to avoid when she experiences back pain during labor?
Supine position
A nurse is assessing a primigravida who was admitted in early labor. She is at 41-weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?
Take a walk around the unit with her. [this helps strengthen and increase contractions]
A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. How should the nurse respond?
Tell the mother, "I'm sorry, but I need to ask you to stay in the waiting area.
When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse's action be to confirm that the membranes have ruptured?
Test the leaking fluid with Nitrazine paper [turns blue if amniotic fluid is present]
A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours after delivery. How does the nurse determine that the uterus is demonstrating appropriate involution?
The amount of lochia rubra is moderate
When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude?
The bladder has become overdistended
The nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when what happens?
The client reports that she feels the urge to move her bowels
The nurse teaches a postpartum client how to care for her episiotomy in order to prevent infection. Which behavior indicates that the teaching has been effective?
The client washes her hands before and after she changes a perineal pad
The nurse is caring for a primigravid client during labor. Which physiologic finding does the nurse observe that indicates birth is about to take place?
The perineum has begun to bulge with each contraction.
Which information should the nurse include in the discharge teaching of a postpartum client?
The prenatal Kegel tightening exercises should be continued
A client in active labor has requested epidural anesthesia for pain management. The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation?
There is a risk of hypotension, and the large amount of IV fluid reduces this risk.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. How should the nurse respond?
These accelerations are a sign of fetal well-being.
A pregnant client is asking the nurse when she will gain the greatest amount of weight during the pregnancy. At which time during prenatal development should the nurse tell the client to expect the greatest fetal and maternal weight gain?
Third trimester
A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result?
This is the desired response at this stage of gestation
The nurse examines a client who has had a cesarean birth. It has been 3 days since the birth, and the client is about to be discharged. Where does the nurse expect the fundus to be located
Three fingerbreadths below the umbilicus [The fundus descends one fingerbreadth per day from the first postpartum day. ]
A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she feels as though she is going to vomit. Which phase of the first stage of labor does the nurse suspect the client has entered?
Transition
A vaginal examination reveals that a client in labor is dilated 8 cm. Soon afterward she becomes nauseated and has the hiccups. The bloody show increases. Which phase of labor does the nurse determine the client is entering?
Transition [most difficult stage in labor]
As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention?
Turn her on the left side
Five minutes after a birth the nurse determines that the client's placenta is separating. Which clinical finding indicates placental separation?
Umbilical cord lengthens
A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse instruct the client to do?
Use the pant-breathing pattern.
At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm, and her contractions are occurring every 4 minutes and lasting 45 seconds. What is the likely cause of these late decelerations?
Uteroplacental insufficiency
The postpartum nurse is delegating tasks to an unlicensed health care worker. Which task should the nurse delegate?
Vital signs on a client 4 hours after delivery
On a 6-week postpartum visit a new mother tells the nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach the mother that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for what?
Vitamin C and iron
A woman in labor hears the primary healthcare provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond?
"A vaginal birth is possible."
What is the best advice a nurse can provide to a pregnant woman in her first trimester?
"Avoid drugs and don't smoke or drink alcohol."
The nurse is teaching participants in a prenatal class regarding breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which response is most appropriate?
"Breastfed infants have fewer infections."
The nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?
"During the eighth week of the pregnancy
A client had a fourth-degree perineal laceration during the birth of her neonate. What should the nurse recommend to protect the area from additional trauma?
"Eat a high-fiber diet with increased fluid intake."
A client who has had a cesarean birth is being discharged. Which statement indicates to the nurse that further teaching is required?
"I don't need perineal care because I didn't give birth through the vagina.
The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious and asks a nurse, "Would it be best for me to leave, since I don't seem to be doing my wife much good?" What is the appropriate response by the nurse?"
"I know that this is hard for you. Let me try to help you coach her during this difficult phase."
What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful?
"I will apply warm packs and massage my breasts before each feeding.
A client is scheduled for a nonstress test in the 37th week of gestation. The nurse explains the procedure. Which statement demonstrates that the client understands the teaching?
"If the heart reacts well, my baby should do OK when I give birth."
During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response? Incorrect 1
"If you add 340 calories a day to your regular diet, you won't become overweight. [women should not be advised to lose weight during pregnancy]
At 40 weeks' gestation a client is admitted to the birthing unit in early labor. She asks the nurse, "Why do you want me to lie on my side?" Which response by the nurse explains the primary purpose of the side-lying position during labor?
"It enhances blood flow to the uterus and makes contractions easier."
A client at 28 weeks' gestation who has gained 13 lb (5.9 kg) tells the nurse in the prenatal clinic that she is glad that she has not gained as much weight as her sister did during her pregnancy. How should the nurse respond?
"Tell me what you've been eating lately."
Which statement made by a pregnant client to a nurse indicates that the client does not understand the teaching regarding fetal growth and development?
"The baby gets food from the amniotic fluid."
The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching?
"The fetus gets nutrients from the amniotic fluid." [no nutrient from the amniotic fluid its just for protection]
In the eighth month of pregnancy a client tells the nurse that she is experiencing dyspareunia. Which information would be most helpful for the nurse to teach the client?
"Try alternative positions."
A pregnant client uses a computer while sitting almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend?
"Try to walk around every few hours during the workday."
During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. Which guidance should the nurse provide regarding sleeping position?
"Turn from side to side."
A postpartum client tells the nurse that she wishes to breast-feed. When the nurse brings her newborn to be breast-fed, the client asks whether she may drink a small glass of wine to help her relax. How should the nurse respond?
"You seem a little tense. Tell me how you feel about breast-feeding."
A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond?
"Your diaphragm has been displaced upward."
A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.8 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response?
"Your weight is expected for someone at 23 weeks' gestation. Continue your current diet." [pt.s should gain 2.2-5.5 lbs during first 12 weeks then 1 pound each week]
The nurse is reviewing the documented results of a lecithin/sphingomyelin (L/S) ratio. Which finding is indicative of fetal lung maturity?
2:1
The nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her regarding minimizing breast discomfort?
ice compression
