Pregnancy, Labor, Childbirth, Postpartum- At Risk
The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? A. Hemorrhage B. Dehydration C. Hypertension D. Subinvolution
A. Hemorrhage Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth.
The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? A. Low birthweight B. Facial abnormalities C. Chronic lung problems D. Hyperglycemic reactions
A. Low birth weight Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.
A 26-year-old G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb (3.6 kg) since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client? A. Mild preeclampsia B. Severe preeclampsia C. Chronic hypertension D. Gestational hypertension
A. Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.
What is the priority nursing intervention during the admission of a primigravida in labor? A. Monitoring the fetal heart rate B. Asking the client when she ate last C. Obtaining the client's health history D. Determining whether the membranes have ruptured
A. Monitoring the fetal heart rate Determining fetal well-being supersedes all other measures; if the fetal heart rate is absent or persistently decelerating, immediate intervention is required. The health history, including the client's last meal and whether the membranes have ruptured, may be taken once fetal well-being has been established.
The nurse is counseling a pregnant client with type 1 diabetes regarding medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy? A. Insulin B. Antihypertensives C. Pancreatic enzymes D. Estrogenic hormones
A. Insulin Usually as pregnancy progresses there are alterations in glucose tolerance and in the metabolism and utilization of insulin. The result is an increased need for exogenous insulin. Antihypertensives are administered only to clients with severe hypertensive preeclampsia. Pancreatic enzymes or hormones other than insulin are not taken by pregnant women with diabetes. Estrogenic hormones are not administered during pregnancy.
A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect? A. Missed abortion B. Inevitable abortion C. Incomplete abortion D. Threatened abortion
D. Threatened abortion Because the cervix is closed, this is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion. Once the cervix is dilated the abortion is inevitable. Portions of the products of conception will have to be passed for a diagnosis of incomplete abortion.
A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor? A. Scheduling pain medication at regular intervals B. Administering the medication only when the pain is severe C. Avoiding the administration of medication unless it is requested D. Recognizing that less pain medication will be needed by this client compared with other women in labor
A. Scheduling pain medication at regular intervals This client will have a lower tolerance for pain and a greater need for pain relief. Larger doses may be needed if pain medication is administered only when the pain is severe. Delays increase anxiety and discomfort, and larger doses will be necessary. Individuals who abuse drugs require more medication than do others because of tolerance to the addictive drug.
While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet begun the bonding process. Which statement by the mother supports the nurse's conclusion? A. "It's such a tiny baby." B. "Do you think he'll make it?" C. "Why does he need to be in an incubator?" D. "My baby looks so much like my husband."
A. "It's such a tiny baby." By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.
A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. Which condition does the nurse suspect? A. Mastitis B. Engorgement C. Blocked milk duct D. Inadequate milk production
A. Mastitis Because of the presence of generalized symptoms, the nurse should suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced.
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's priority intervention? A. Inserting a urine retention catheter B. Administering oxygen by means of nasal cannula C. Helping the client turn to the side-lying position D. Encouraging the client to pant with her next contraction
C. Helping the client turn to the side-lying position Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urine retention catheter is unnecessary; in addition, it requires a primary healthcare provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? A. Cerebral hemorrhage B. Pulmonary edema C. Impending seizures D. Hypovolemic shock
D. Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? A. Face B. Brow C. Breech D. Shoulder
C. Breech In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.
A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate? A. Hypertension B. Hypoglycemia C. Chilling and shivering D. Bleeding and infection
D. Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate, because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.
A nurse is assessing a woman with a probable ruptured tubal pregnancy. What clinical manifestation requires immediate intervention? A. Abdominal distention B. Intermittent abdominal contractions C. Dull, continuous upper-quadrant abdominal pain D. Sudden onset of knifelike pain in one of the lower quadrants
D. Sudden onset of knifelike pain in one of the lower quadrants One symptom of sudden rupture of a fallopian tube is pain on the affected side, usually sudden, excruciating, and radiating over the lower abdomen and to the shoulder; sometimes the pain is associated with nausea, vomiting, and diarrhea. Abdominal distention is not a classic sign of a ruptured fallopian tube. There are no contractions, because the pregnancy is not uterine. The pain is exquisite, sharp (not dull) and sudden in the lower abdomen when the fallopian tube ruptures.
A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life? A. 2:1 B. 1:1 C. 1:4 D. 3:4
A. 2:1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4.
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action? A. Administering oxygen B. Elevating the head of the bed C. Drawing blood for a hematocrit level D. Giving an intramuscular analgesic
A. Administering oxygen Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary healthcare provider's prescription.
A client in the thirty-eighth week of gestation exhibits a slight increase in blood pressure. The primary healthcare provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? A. "It increases blood flow to the fetus." B. "It decreases intra-abdominal pressure." C. "It increases the mean arterial pressure." D. "It prevents the development of thrombosis."
A. "It increases blood flow to the fetus." The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bed rest the blood pressure decreases. The side-lying position does not prevent thrombosis; bed rest and immobility may increase the risk of thrombosis.
A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How would the nurse evaluate the client for bladder distension? A. By catheterizing the client for residual urine B. By palpating the client's suprapubic area gently C. By asking the client whether she still feels the urge to urinate D. By determining whether the client is experiencing suprapubic pain
B. By palpating the client's suprapubic area gently Palpation will indicate whether bladder distention is present. The increased intra-abdominal space available after birth can result in bladder distention without discomfort. Assessment should be done before interventions. Trauma to the area makes surrounding organs atonic; the client may have a full bladder and not feel the urge to void.
A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider regarding breech presentations when caring for this client? A. Severe back discomfort will occur. B. Length of labor usually is shortened. C. Cesarean birth probably will be necessary. D. Meconium in the amniotic fluid is a sign of fetal hypoxia.
C. Cesarean birth probably will be necessary. A cesarean birth may be performed when the fetus is in the breech presentation because the risk of morbidity and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation because the buttocks are not as effective as the head as a dilating wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation, because contractions compress the fetal intestinal tract, causing release of meconium.
The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next? A. Ambulating the client to promote circulation B. Inserting two small-bore intravenous catheters C. Determining whether the client feels safe at home D. Ensuring that the client has her glasses to ambulate
C. Determining whether the client feels safe at home Bruising on the backs of back shoulders and both wrists indicates potential abuse; asking the client whether she feels safe at home will open a dialogue to discuss the possible physical abuse. Whether or not the client admits abuse, the nurse is required to report the finding. A client in preterm labor should have a large-bore intravenous catheter. Ambulation is not appropriate for a client in preterm labor, and bed rest should be maintained. Reporting should not be delayed.
A client admitted to the high-risk unit with a threatened abortion anxiously asks the nurse, "Could this have happened because I had the flu?" How should the nurse respond? A. "Tell me why you feel this way. Do you think that you did something to cause the bleeding?" B. "We know that maternal infection sometimes results in spontaneous abortion. Perhaps the flu did cause it." C. "I'm sure that there's nothing you could have done to cause this. You shouldn't worry about it." D. "The primary healthcare provider will be here soon and will be better prepared to answer your questions. Why don't you wait until then?"
A. "Tell me why you feel this way. Do you think that you did something to cause the bleeding?" Asking the client to talk about how she feels encourages the client to discuss her fears and anxieties. Stating that the flu may have caused the spontaneous abortion gives inaccurate information; this conclusion has not been documented, and this response adds to the guilt felt by the client. Telling the client that there is nothing she could have done to cause the problem does not focus on the client's feelings; it cuts off communication between the nurse and the client. Telling the client to wait until the primary healthcare provider arrives denies the client's feelings, abdicates the nurse's responsibility to the client, and cuts off communication. Also, it may increase anxiety because it implies that the nurse is not adequately prepared to care for the client.
The nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention at this time? A. Giving a detailed explanation of what may have caused the stillbirth B. Providing the parents the opportunity to say goodbye to their newborn C. Explaining that autopsy is not recommended in the setting of a stillbirth D. Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief
B. Providing the parents the opportunity to say goodbye to their newborn Parents should be given the opportunity to say goodbye to a stillborn baby. Because the parents may not think to ask to see the baby, the nurse should provide this opportunity. Giving a detailed explanation of possible causes of the stillbirth is nontherapeutic. An autopsy may be performed when there is a stillbirth. The decision is left to the parents. The procedure can be very important in answering the question "Why?" if there is a chance that the cause of death can be determined. Before the parents leave the hospital, arrangements for follow-up care should be made. This information should be provided immediately, because it can help the parents begin the grieving process. Many hospitals have a team consisting of a social worker, chaplain, and nurse that is called when a stillbirth occurs.
A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene? A. Hyperactive sensorium B. Increase in respiratory rate C. Lack of the knee-jerk reflex D. Development of a cardiac dysrhythmia
C. Lack of the knee-jerk reflex Magnesium sulfate has a depressant effect on the central nervous system; therefore a toxic level will be reflected by the loss of the knee-jerk reflex. The level of consciousness is decreased with excessive magnesium sulfate. There is a deceleration in the respiratory rate with magnesium sulfate toxicity. Development of a cardiac dysrhythmia may be caused by increased potassium, not magnesium sulfate.
A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond? A. "It must be difficult to lose this baby that was important to you both." B. "This is nature's way of dealing with babies that may have problems." C. "A curettage will give you a new start. I'll bet you'll get pregnant again soon." D. "You must be disappointed, but don't feel guilty. These things sometimes happen."
A. "It must be difficult to lose this baby that was important to you both." The response "It must be difficult to lose this baby that was important to you both" acknowledges the loss and the grieving process. It also encourages the expression of feelings. Suggesting that "this is nature's way" minimizes the loss and may reflect the nurse's beliefs. Predicting that another pregnancy will occur soon does not acknowledge the loss and cuts off communication. Guilt feelings were never expressed by the client.
A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate? A. Cesarean birth B. Prolonged labor C. Rapidly induced labor D. Vacuum extraction vaginal birth
A. Cesarean section Immediate birth is necessary to prevent fetal hypoxia and death. Allowing a prolonged labor, inducing labor, or using vacuum extraction in a vaginal birth will increase pressure on the cord, resulting in fetal hypoxia.
During a follow-up appointment, a client at 21 weeks' gestation is diagnosed with hyperemesis gravidarum. The client says, "Why is this happening to me? I don't know whether I can go on like this." What is the ideal response by the nurse? A. "Are you saying that you want to schedule an abortion?" B. "This must be physically and emotionally challenging for you." C. "We're doing the best we can here, so please be patient with us." D. "There are dietary changes and medications available that can ease the nausea."
B. "This must be physically and emotionally challenging for you." An open-ended statement validates what the client is experiencing and will encourage further client expression. It is not clear that the client has expressed a desire to have an abortion. It is important to open the lines of communication so the client may express her concerns. Becoming defensive is not in the best interest of the client. This would close down communication. It is true that there are dietary and medication options that can help, but validation of the client's feeling and encouraging open expression is the first priority; only after this is done will the client be ready to listen.
A pregnant client with a history of preterm labor is at home on bed rest. Which instructions should be included in this client's teaching plan? A. Place blocks under the foot of the bed B. Sit upright with several pillows behind the back C. Lie on the side with the head raised on a small pillow D. Assume the knee-chest position at regular intervals throughout the day
C. Lie on the side with the head raised on a small pillow Bed rest keeps the pressure of the fetal head off the cervix. The side-lying position keeps the gravid uterus from impeding blood flow through major vessels, thus maintaining uterine perfusion. The Trendelenburg position is used when the cord is prolapsed or the client is in shock. Sitting up in bed increases pressure on the cervix and could lead to further dilation. Assuming the knee-chest position at regular intervals throughout the day may help relieve pressure of the fetus on the cervix; however, it will not enhance uterine perfusion.
While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? A. True labor B. Placenta previa C. Partial abruptio placentae D. Abdominal muscular injury
C. Partial abruptio placentae Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.
A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy? A. Fetal tachycardia B. Presence of leukorrhea C. Premature rupture of membranes D. Imminence of the estimated date of birth
C. Premature rupture of membranes Ruptured membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common because of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. Intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed because of the enlarged abdomen.
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? A. The client does not have an infection. B. The donor blood is free of bloodborne pathogens. C. The nurse should have worn gloves for self-protection. D. The nurse was skilled enough to prevent exposure to the blood.
C. The nurse should have worn gloves for self-protection. The Centers for Disease Control and Prevention (CDC) recommends that gloves be worn when there is the potential for contact with blood or other body fluids. Even if the client does not have an infection, gloves are always worn when exposure to blood or other body fluids is a possibility. All blood is considered potentially infectious. Nurses are required to take precautions that limit exposure; gloves must be worn.
A client in labor at 39 weeks' gestation is told by the primary healthcare provider that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth? A. Gonorrhea B. Chlamydia C. Chronic hepatitis D. Active genital herpes
D. Active genital herpes Once the membranes have ruptured, the active herpes infection ascends and can infect the fetus; because herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, Chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacologic.
A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? A. Hydatidiform mole B. Vena cava syndrome C. Marginal placenta previa D. Complete abruptio placentae
D. Complete abruptio placentae Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.
A client's labor has progressed to the point where she is 6 cm dilated; however, the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What other nursing action should be performed at this time? A. Inspecting the perineum B. Preparing for an immediate birth C. Measuring the maternal blood pressure D. Increasing the intravenous (IV) fluid rate
A. Inspecting the perineum After the rupture of membranes, the umbilical cord may prolapse if the fetal head does not engage immediately, and this can lead to fetal compromise. The perineal area should be inspected at this time and frequently thereafter for evidence of cord prolapse. Rupture of the membranes does not lead to precipitous birth; it is done to facilitate labor. Rupture of membranes is not associated with maternal blood pressure changes. Increasing the IV rate is appropriate if the client shows signs of dehydration; the data do not indicate this.
The nurse is caring for a client in her third trimester who is scheduled for an amniocentesis. What should the nurse do to prepare the client for this test? A. Instruct her to void immediately before the test. B. Tell her to assume the high Fowler position before the test. C. Encourage her to drink three glasses of water before the test. D. Advise her to take nothing by mouth for several hours before the test.
A. Instruct her to void immediately before the test The client is instructed to void immediately before the test to help prevent injury to the bladder as the needle is introduced into the amniotic sac. The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract.
The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? A. Prolong the course of labor B. Cause decreased placental perfusion C. Lead to transient episodes of hypertension D. Interfere with free movement of the coccyx
B. Cause decreased placental perfusion In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? A. Calling the primary healthcare provider B. Changing the maternal position C. Obtaining the maternal blood pressure D. Preparing the environment for an immediate birth
B. Changing the maternal position The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth.
The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? A. Calling the primary healthcare provider B. Checking the client's reflexes C. Determining the client's blood type D. Administering the prescribed intravenous (IV) normal saline
B. Checking the client's reflexes The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.
The postpartum nurse has just received report on four clients. Which client should the nurse evaluate first? A. Client who vaginally delivered a 7-lb (3175 g) baby 1 hour ago B. Client who vaginally delivered a 9-lb (4082 g) baby 1 hour ago C. Client who vaginally delivered a preterm baby 4 hours ago D. Client who had a planned cesarean delivery of an 8-lb (3629 g) baby 2 hours ago
B. Client who vaginally delivered a 9-lb (4082 g) baby 1 hour ago The nurse should assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An overdistended uterus caused by a large fetus (9-lb; 4082 g) can result in uterine atony. Delivering a 7-lb baby (3175 g) or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.
During their initial visit to the prenatal clinic, a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? A. Recent history of drug abuse B. Family history of genetic abnormalities C. Maternal age older than 30 years at the time of the first pregnancy D. Request by client to determine sex of fetus
B. Family history of genetic abnormalities Amniocentesis is usually reserved for those women considered at higher risk of carrying a fetus with a chromosomal or genetic abnormality. The main reason for performing amniocentesis is the diagnosis of genetic problems. Even though a recent history of drug abuse may increase the risk of the development of the fetus, it is not a genetic issue. A history of more than three prior spontaneous abortions is not a reason to perform this invasive procedure. The risk will outweigh the benefit and will increase the risk of another spontaneous abortion. Amniocentesis is no longer performed routinely if the client is an older primigravida. A sonogram is performed first. Determining the sex with an amniocentesis puts the mother at high risk for complications. Other less invasive procedures can be done to determine sex of fetus.
A sonogram performed on a client in the third trimester reveals a low-lying placenta. What should the nurse teach the client that she is at risk for? A. Sharp abdominal pain B. Painless vaginal bleeding C. Increased lower back pain D. Early rupture of membranes
B. Painless vaginal bleeding This client's placenta is implanted near the internal cervical os; in the latter part of pregnancy, as the process of effacement occurs, placental separation from the uterus causes painless bleeding. Sharp abdominal pain occurs with abruptio placentae, the premature separation of a normally situated placenta. Increased lower back pain is not specific to a low-lying placenta. Early rupture of membranes is not specific to a low-lying placenta.
The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? A. Postpartum hemorrhage is an expected complication. B. Perinatal mortality is two to three times more likely in multiple than in single births. C. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. D. Maternal mortality is higher during the prenatal period in the setting of multiple gestation.
B. Perinatal mortality is two to three times more likely in multiple than in single births. Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? A. Head compression B. Maternal hypothyroidism C. Uteroplacental insufficiency D. Umbilical cord compression
C. Uteroplacental insufficiency Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.
A client who is admitted to the high-risk unit with severe preeclampsia anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? A. "There is no way of telling at this time what the outcome will be." B. "Your baby probably will be all right. It's protected by the amniotic fluid." C. "If you follow your primary healthcare provider's instructions, everything will progress normally." D. "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat."
D. "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat." Telling the client that the baby's condition will constantly be monitored reassures the client of the well-being of the fetus at the moment and indicates that the nurses are aware of and are monitoring the fetus's status. Saying that there is no way to know the outcome does not provide the mother with any reassurance of the status of the fetus or that anything is being done to monitor the fetus. Promising that the baby will be all right provides false reassurance; amniotic fluid will not protect the fetus if the mother has a seizure. Suggesting that everything will progress normally if the client follows the primary healthcare provider's instructions provides false reassurance; following instructions does not guarantee a healthy newborn.
Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal pregnancy? A. A painful, tender area in the epigastric region after meals B. Lower abdominal cramping of 1 week's duration with constipation C. Leukorrhea or dysuria occurring a few days after the first missed menstrual period D. A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder
D. A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder A fallopian tube is unable to contain and sustain a pregnancy to term; as the fertilized ovum grows, there is excessive stretching or rupture of the affected fallopian tube, resulting in pain. At this stage the products of conception are too small to form a mass; the pain is lateral, not centered. The pain is sudden, intense, and knifelike, not prolonged or cramping. Leukorrhea and dysuria may be indicative of a vaginal or bladder infection.
A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use? A. Number of clots that were passed B. Changes in fetal activity when bleeding C. Increased weakness since bleeding began D. Amount of blood lost in relation to usual menstrual flow
D. Amount of blood lost in relation to usual menstrual flow Determining the amount of blood lost in relation to her usual menstrual flow gives the client a familiar gauge with which to estimate the amount of bleeding she is experiencing. The presence of clots does not indicate the amount of bleeding. Changes in fetal activity may indicate a problem, but there is no relationship to the amount of bleeding. Weakness is a subjective symptom and may not reflect blood loss.
During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of large and painful varicose veins. In light of this information, what should the nurse's assessment include? A. Monitoring daily clotting times B. Assessing for peripheral pulses C. Monitoring daily hemoglobin values D. Assessing for signs of thrombophlebitis
D. Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.
A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and is 60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood from the vagina. The uterus is irritable upon palpation and does not relax fully between contractions. What is the initial nursing action? A. Transporting the client for a cesarean birth B. Checking the perineum for rupture of membranes C. Changing the underpad and positioning the client on her left side D. Assessing the fetal heart rate, uterine activity, and blood pressure
D. Assessing the fetal heart rate, uterine activity, and blood pressure The client should be evaluated for signs of abruptio placentae with an assessment for cessation of uterine activity, fetal heart rate decelerations, and falling blood pressure. The status of fetus and mother must be assessed before any other nursing action (transporting the client for a cesarean birth or changing the underpad and positioning the client on her left side) is taken. Checking the perineum for rupture of membranes is not the priority during this emergency situation.
What is the primary responsibility of a nurse teaching the pregnant adolescent? A. Instructing her about the care of an infant B. Informing her of the benefits of breast-feeding C. Advising her to watch for danger signs of preeclampsia D. Encouraging her to continue regularly scheduled prenatal care
D. Encouraging her to continue regularly scheduled prenatal care It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.
