NUR 2420 Maternal Nursing Chapter 11: Maternal Adaptation During Pregnancy

A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse?

"A one time discharge of bloody mucus in the toilet might have been your mucus plug."

During a visit to the clinic, a client in the first trimester tells the nurse, "My nose is so stuffy, lately. Could I have a cold?" Which response by the nurse is appropriate?

"A stuffy nose is common in pregnancy because of high estrogen levels."

The nurse is caring for a client at 8 weeks' gestation who states, "I did not plan for this right now and I am not happy or excited about this pregnancy. I am not sure what to do." Which response by the nurse is best?

"Many women feel this way during the first trimester."

A urinalysis is done on a client in her third trimester. Which result would be considered abnormal?

2+ Protein in urine

A 23-year-old female has come to the clinic for her first prenatal visit. After the examination reveals no concerns and potential low-risk pregnancy, the nurse discusses nutritional needs for her and her growing baby. As per the Institute of Medicine, the nurse suggests the client take which amount of ferrous iron daily?

27 mg

The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?

Darkened breast areolae

The nurse cares for a pregnant client at the first prenatal visit and reviews expected changes that will occur during pregnancy. Which information will the nurse include in the education?

During pregnancy blood volume can increase by at least 40%.

A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she has been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely?

Fundal height has dropped since the last recording.

In preparing for a prenatal class to discuss the hormonal changes during pregnancy, which information would the nurse most likely include?

Over-the-counter antacids can be used to treat acid reflux with the health care provider's knowledge.

During an examination, a client at 32 weeks' gestation becomes dizzy, lightheaded, and pale while supine. What should the nurse do first?

Turn the client on her left side.

The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply.

breast changes amenorrhea morning sickness

A nurse is caring for a pregnant client who has been diagnosed with lordosis. The nurse offers preventive measures for which consequence of lordosis when caring for this client?

chronic backache

During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called?

couvade syndrome

A pregnant client arrives at the maternity clinic reporting constipation. Which factors could be the cause of constipation during pregnancy? Select all that apply.

decreased activity level use of iron supplements intestinal displacement

A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to:

encourage her to identify someone that she can talk to and share the pregnancy experience.

A client's menstrual period is two weeks late. She has been feeling tired and has had episodes of nausea in the morning. What classification of pregnancy symptoms is this client experiencing?

presumptive

A 27-year-old female was just confirmed to be pregnant. She tells the nurse she just switched to a vegan diet. The nurse explains that she must pay special attention to her intake of which elements to ensure she is getting adequate nutrition for her and the baby? Select all that apply.

protein iron vitamin B12 calcium

The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?

ultrasound picture of her fetus

A client in her 39th week of gestation reports swelling in the legs after standing for long periods of time. The nurse recognizes that this factor increases the client's risk for which condition?

venous thrombosis

A client who has just given a blood sample for pregnancy testing in the health care provider's office asks the nurse what method of confirming pregnancy is the most accurate. The nurse explains the difference between presumptive symptoms, probable signs, and positive signs. What should the nurse mention as an example of a positive sign, which may be used to diagnose pregnancy?

visualization of the fetus by ultrasound