Pregnancy, Labour, Childbirth, Postpartum - Uncomplicated
Which response would the nurse give to a newly delivered client who asks to take the placenta home with her upon discharge?
"I need to check the hospital protocol for our policy on that practice." The placenta is a part of the body and contains body fluids. It must first be assessed by the health care provider to be sure that it is not infected and to be sure that all parts of the placenta have been accounted for. The nurse must follow hospital protocol regarding the release of the placenta to the family. All necessary documentation must be signed and the policies must be followed before the release of the placenta to the family.
Which direction regarding sleeping position would the nurse give to a client who is 8 months' pregnant?
"Turn from side to side when in bed." The side-lying position will relieve back pressure; it also promotes uterine perfusion and fetal oxygenation. At 32 weeks' gestation the abdomen is too distended for the pregnant woman to lie in the prone position. Elevating the head of the bed will not relieve back pressure; it is used to limit gastroesophageal reflux. Lying on the back is contraindicated because it puts pressure on the vena cava, resulting in hypotension and uteroplacental insufficiency. Pillows under the knees are contraindicated because they place pressure on the popliteal area, which compresses the venous circulation, increasing the risk of thrombophlebitis.
Which statement indicates that a pregnant client requires further teaching about fetal growth and development? 1. "The fetus keeps growing throughout pregnancy." 2. "The fetus gets nutrients from the amniotic fluid." 3. "The fetus may be underweight if it's exposed to smoke." 4. "The fetus gets oxygen from blood coming through the placenta."
2. The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.
A prenatal client's vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client's clinical record?
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.
Which condition is detected by an alpha-fetoprotein test?
The alpha-fetoprotein test detects neural tube defects, Down syndrome, and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.
Which information would tell the nurse if a woman at 40 weeks' gestation having contractions is in true labor?
The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.
Which pH value of amniotic fluid is indicated by a Nitrazine test strip that turns deep blue?
7.5 Amniotic fluid changes the color of a nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5, or 6.5 would result in a test strip of yellow, olive yellow, or blue green, respectively.
Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? 1. Pica 2. Caffeine intake 3. Alcohol abuse 4. Artificial sweetener use
1. The practice of pica, especially the ingestion of heavy metals, must be considered when pregnant women are found to be anemic. Caffeine, alcohol, and artificial sweeteners are not directly linked to anemia in pregnant women.
The nurse is caring for a primigravid client during labor. Which physiological finding would the nurse observe that indicates birth is about to take place?
The perineum has begun to bulge with each contraction. The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. An increase in bloody show (discharge from the vagina) and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent.
Between contractions that are 2 to 3 minutes apart and last about 45 seconds the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. Which is the priority nursing action? 1. Notify the health care provider. 2. Resume continuous fetal heart monitoring. 3. Continue to monitor the maternal vital signs. 4. Document the fetal heart rate as an expected response to contractions
1. Notify HCP. The expected FHR is 110 to 160 beats/min between contractions. An FHR of 100 beats/min is bradycardia (baseline FHR slower than 110 beats/min) and indicates that the fetus may be compromised, requiring notifying the health care provider and medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. Although a fetal heart rate slower than 110 beats/minute should be documented, it is not an expected response.
A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). Which interpretation pertains to this result? 1. Immediate birth is indicated. 2. This is the desired response at this stage of gestation. 3. Further testing is unnecessary with this desired outcome. 4. The result is inconclusive, indicating the need for further evaluation
2. An NST indicates that the fetus is healthy because there is an active pattern of fetal heart rate acceleration with movement. The result is positive and desired; immediate birth is not required. Further testing is needed. If the pregnancy continues, another test of fetal well-being will probably be done. The results were positive, not inconclusive.
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. Which action would the nurse take after obtaining the fetal heart rate and maternal vital signs? 1. Teach the client how to push with each contraction. 2. Provide the client with comfort measures for relaxation. 3. Prepare to have the client's blood typed and cross-matched. 4. Encourage the client to perform patterned, paced breathing.
2. The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor.
Which physiological alteration does the nurse expect in a client's hematological system during the second trimester of pregnancy?
An increase in blood volume The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks' gestation. The hematocrit decreases as a result of hemodilution. The sedimentation rate increases because of a decrease in plasma proteins. WBCs count increases somewhat starting in the second trimester and peak in the third. WBCs are in the 5000 to 15,000 range during pregnancy.
Which recommendation would the nurse provide the client with fluid retention during pregnancy?
Elevate the lower extremities. Elevation of the extremities several times daily is recommended to ease dependent edema. Fluid intake should be encouraged because adequate hydration maintains fluid and electrolyte balance. The client should not maintain a high-sodium diet because of the fluid retention. Sodium intake should be limited, but not completely restricted, because it is necessary to balance the increased fluid volume needs during pregnancy. Diuretics can be harmful and are not used during a healthy pregnancy.
Which interventions are included in the immediate care plan of a postpartum client with a fourth-degree laceration?
Providing pain management will prevent the client's pain from reaching an unmanageable level. Assessment of the site will identify any abnormal changes. Application of ice will decrease pain and edema. Warmth applied to newly traumatized tissue will increase pain and edema. Antibacterial cleanser would be caustic and painful to the laceration. Teaching regarding bowel function would be more appropriately presented after the client has resumed normal intake.
Which is the most appropriate response when a client asks if the nurse thinks the ordered nonstress test is necessary?
"You seem to have doubts about this test." Observing that the client is having doubts encourages her to discuss her fears and anxieties. Telling the client that the test is fast, harmless, or routine cuts off communication and does not allow the client to express her fears and anxiety. The mention of risk may frighten the client and does not encourage the client to discuss the situation further.
The nurse explains to a client that she will need additional calcium during pregnancy and that the ideal source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." Which is an appropriate reply?
"Your practitioner can prescribe calcium supplements." Calcium is essential to a pregnant woman's diet for the development of the fetal skeleton; it must be supplemented if the client dislikes or is allergic to milk and milk products. A nutritionally sound diet without dairy products does not meet the needs of the pregnant woman or her fetus. Dental care and oral hygiene will be more beneficial for maintaining healthy teeth than adding more calcium to the diet will. If milk makes the client ill, the statement "Drinking milk is so important for your baby to develop strong bones" is ineffective advice, and the dietary regimen probably will not be followed.
Which statements regarding the involution process are correct? Select all that apply: 1. Involution begins immediately after expulsion of the placenta. 2. Involution is the self-destruction of excess hypertrophied tissue. 3. Involution progresses rapidly during the next few days after birth. 4. Involution is the return of the uterus to a nonpregnant state after birth. 5. Involution may be caused by retained placental fragments and infections
1, 3 & 4. The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.
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." Which action would the nurse take to confirm that the membranes have ruptured? 1.Take the client's oral temperature. 2. Test the leaking fluid with nitrazine paper. 3. Obtain a clean-catch urine specimen. 4. Inspect the perineum for leaking fluid.
2. Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the initial assessment. Although this may be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic fluid. Inspecting the perineum for leaking fluid will not confirm rupture of the membranes.
Which action provides support for the fetal head as it is being delivered? 1. Applying suprapubic pressure 2. Placing a hand firmly against the perineum 3. Distributing the fingers evenly around the head 4. Maintaining pressure against the anterior fontanel
3. Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.
After a client gives birth, which physiological 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 When the placenta separates from the uterine wall, it tears blood vessels, resulting in a gush of blood from the vagina. The uterus should become firm when the placenta begins to separate. The fundus rises in the abdomen when the placenta separates. The cord does not retract into the vagina; in fact, the reverse occurs: As the placenta separates it descends into the vaginal introitus, after which the umbilical cord appears longer and protrudes from the vagina.
Which cervical changes are observed during pregnancy?
By the beginning of the sixth week of pregnancy, the cervical tip softens. During pregnancy, the cervical muscle and its collagen-rich connective tissues increase in volume and become loose and highly elastic. Cervical tissue fragility also increases. The external cervical os appears as a jagged slit postpartum; however, it does not during pregnancy.
Which assessment findings support the conclusion that a client is entering the transition phase of the first stage of labor?
Increased bloody show, irritability, and shaking Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. A bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.
Where is the presenting part of the fetus when station is -1?
Station -1 signifies that the fetal head is 1 cm above the ischial spines and has not reached the vaginal canal. When the fetal head is 1 cm below the ischial spines, it is at station +1. When the fetal head is visible at the vaginal opening, it is at station +4. When the fetal head is level with the ischial spines, it is at station 0.
Which client statement indicates understanding of teaching about a nonstress test? 1. "I'll need to have an intravenous (IV) line so the medication can be injected before the test." 2. "My baby may get very restless after I have this test." 3. "I hope this test doesn't cause my labor to start too early." 4. "If the heart reacts well, my baby should do OK when I give birth."
The nonstress test is used to evaluate the response of the fetus to movement and activity. A reactive test indicates that the fetus is healthy. No injections of any kind are used during a nonstress test; it involves only the use of a fetal monitor to record the fetal heart rate during periods of activity. The nonstress test will not influence the activity of the fetus because no exogenous stimulus is used. Early labor is unlikely because the nonstress test is noninvasive.
Which statement made by a pregnant client after a prenatal class on fetal growth and development indicates the need for additional teaching? 1. "The baby is smaller if the mother smokes." 2. "The baby gets food from the amniotic fluid." 3. "The baby's oxygen is provided by the mother." 4. "The baby's umbilical cord has 2 arteries and 1 vein."
2. The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, to supply blood containing nutrients and oxygen. "The baby is smaller if the mother smokes," "The baby's oxygen is provided by the mother," and "The baby's umbilical cord has 2 arteries and 1 vein" are all true statements, and further teaching would not be required.
Which statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? 1. "I will take a cool shower before each feeding." 2. "I will drink a couple of quarts of fat-free milk a day." 3. "I will wear a snug-fitting breast binder day and night." 4. "I will apply warm packs and massage my breasts before each feeding."
4. Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed.
Which statement by a client who was normal weight before pregnancy indicates the need for further teaching regarding weight gain guidelines? 1. "I should gain 25 to 35 pounds total during the pregnancy." 2. "I shouldn't try to lose weight or cut calories while pregnant." 3. "I should gain 1 to 2 pounds per week through the entire pregnancy." 4. "I may need additional testing if I gain more than 6 to 7 pounds in 1 month."
3. Women should gain only about 2.2 to 4.4 pounds in the first trimester, and 1 pound per week in the second and third trimesters, for a total of 25 to 35 pounds throughout the pregnancy. Higher weight gain than normal, more than 6 to 7 pounds in 1 month, will warrant additional investigation because it can be a sign of preeclampsia. Weight loss and cutting calories are not appropriate during pregnancy due to the risk of malnutrition to both mother and baby.
When assessing a client who gave birth 1 day ago, the nurse finds the fundus is firm at 1 fingerbreadth below the umbilicus and the perineal pad is saturated with lochia rubra. Which is the nurse's next action? 1. Recording these expected findings 2. Obtaining a prescription for an oxytocic medication 3. Asking the client when she last changed the perineal pad 4. Notifying the primary health care provider of excessive bleeding
3. the amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia, so asking the client when she last changed the perineal pad is appropriate. These findings cannot be supported or recorded without additional information. Excessive bleeding cannot be established without more information from the client. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus.
A client's membranes rupture when her cervix is dilated to 7 cm, and the fetal head is at station +1. Which action would the nurse take in response to this situation? 1. Notify the practitioner. 2. Observe the vaginal opening for a prolapsed cord. 3. Reposition the client on a sterile towel on her left side. 4. Check the fetal heart rate while observing the color of the amniotic fluid.
4. Check the fetal heart rate while observing the color of the amniotic fluid. Fetal well-being is the priority. The fetal heart rate will reflect the fetus's response to the rupture of the membranes, and the color of the amniotic fluid will reveal whether there is meconium staining. Notifying the practitioner is necessary if the nurse's assessments reveal fetal compromise. Although checking the vaginal opening for cord prolapse is important, it is not the priority; the fetal head is engaged at station +1. Although positioning the client on the left side promotes placental perfusion, it is not the priority, and a sterile pad is not needed.
Which is a sensory simulation strategy a laboring client can use as a nonpharmacological strategy for pain management? 1. Gentle massage of the abdomen 2. Biofeedback-assisted relaxation techniques 3. Application of a heat pack to the lower back 4. Selecting a focal point and beginning breathing techniques
4. Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.
When can a primigravida fetal heartbeat be heard for the first time?
A fetal heartbeat can be obtained at 10 to 12 weeks with electronic Doppler ultrasound. The heartbeat cannot be obtained with a stethoscope, and 4 weeks is too early to hear a fetal heart. A fetoscope cannot pick up the heartbeat until the 17th week. The heart rate can be detected 8 to 10 weeks earlier than 20 weeks.
Which is an appropriate response to a client who is 8 weeks pregnant and is concerned because she doesn't "feel like making love to her husband since becoming pregnant" and she doesn't "think he understands"?
"A decrease in libido is common during the first trimester of pregnancy." Often the pregnant woman experiences a decrease in sexual desire during the first trimester, probably as a result of nausea and vomiting; if couples are informed about this, they are less likely to become distressed
Which phrase describes the location of the presenting part when the fetus is at +1 station?
A +1 station indicates that the fetal presenting part is 1 cm below the ischial spines, which are the points of engagement. Entrance of the pelvic inlet is designated as 0 station or as a negative number. The head must be at +3 to +5 to be visible at the vaginal opening.
Which direction would the nurse give to a 3-day postpartum client who reports that her breasts are so painful that she dreads breast-feeding the baby?
Express some milk manually before feeding to relieve pressure. The pressure and tenderness resulting from accumulated milk can be relieved by manually expressing some of the fluid before feeding. Pain medication may be taken if other measures are unsuccessful; however, medication can be transferred to the infant through breast milk. Also, giving medication is a dependent function of the nurse that requires a prescription. Breast-feeding, not formula feeding, should continue as a means of limiting engorgement and aiding milk production. The mother should not limit fluids, especially if she is breast-feeding.
Which preventable diseases pose a particular risk for pregnant women and their infants? Select all that apply. One, some, or all responses may be correct.
The pregnant woman's immunization record should be reviewed for vaccinations against rubella, varicella, pertussis, hepatitis B, and seasonal influenza. Human papillomavirus is not one of the diseases that poses a particular risk for pregnant women and their infants.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During an NST, the client asks what it means when the fetal heart rate goes up every time the fetus moves. Which is an appropriate response? 1. "These accelerations are a sign of fetal well-being." 2. "These accelerations indicate fetal head compression." 3. "Umbilical cord compression is causing these accelerations." 4. "Uteroplacental insufficiency is causing these accelerations."
1. The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.
One hour after a birth the nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and 2 fingerbreadths below the umbilicus. Which would the nurse do next? 1. Encourage the client to void. 2. Notify the health care provider immediately. 3.Massage the uterus and attempt to express clots. 4. Continue periodic assessments and record the findings.
4. Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded. Encouraging the client to void is unnecessary; if the bladder is full, the uterus will be higher and pushed to one side. Notifying the health care provider is unnecessary; involution is occurring as expected. Massage is used when the uterus is soft and "boggy."
According to Naegele rule, which is the expected date of delivery (EDD) of a client whose last menstrual period began on April 15?
January 22nd. To determine EDD with the use of Naegele rule, subtract 3 months from the date of the last menstrual period and add 7 days; in this case the EDD is January 22.
A number of routine screens are performed on the pregnant client during the course of her gestation. Place the tests in order from first to last test done. 1. Serum glucose for gestational diabetes 2.Fetal movement test 3.Group B streptococcus culture 4.Sickle cell screening 5.Alpha-fetoprotein (AFP) testing for neural tube defects
Sickle cell screening, particularly for black women, should be done on the initial visit. AFP testing for neural tube defects should be done between 14 and 16 weeks. Serum glucose testing for gestational diabetes should be done between 26 and 28 weeks. Fetal movement tests may be started at 28 weeks' gestation because the fetus' pattern of movement becomes stabilized at this time. Group B streptococcus culture should be done between 36 and 38 weeks.
Which result after 20 minutes of a nonstress test is suggestive of fetal reactivity?
Two accelerations of 15 beats/min lasting 15 seconds According to the American Congress of Obstetricians and Gynecologists, fetal reactivity is a fetal tracing 15 beats' acceleration above baseline lasting 15 seconds or more, normal baseline rate, and long-term variability amplitude of 10 or more beats/min. An absence of long-term variability is an ominous sign that must be addressed. An above-average baseline heart rate is acceptable up to 160 beats/min. An increasing baseline heart rate is a sign of maternal infection. Contractions are not expected with a nonstress test; early, late, or variable fetal heart rate decelerations are associated with uterine contractions.
Which information would the nurse include in the discharge teaching of a postpartum client? 1. The prenatal Kegel tightening exercises should be continued. 2. A bowel movement may not occur for up to a week after the birth. 3. The episiotomy sutures will be removed at the first postpartum visit. 4. A postpartum checkup should be scheduled as soon as menses returns.
1. Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.
Which type of pelvis is considered the most favorable for a vaginal delivery?
A gynecoid pelvis is considered the most favorable for a vaginal birth because the inlet allows the fetus room to easily pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus would have difficulty passing through this shape of pelvis. The anthropoid pelvis is elongated, with a roomy anteroposterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.
When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action would the nurse implement at this time? 1. Having her pant-blow during contractions 2. Placing her legs in stirrups to facilitate pushing 3. Encouraging her to bear down with each contraction 4. Reviewing the pushing techniques taught in childbirth classes
1. Although there are exceptions, the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing. Pushing may cause cervical trauma when the cervix is not completely dilated. It is too early to prepare for the second stage of labor or to have the client bear down with each contraction if the cervix is not fully dilated. At this time the client is completely introverted and will be unreceptive to a review of pushing techniques.
For which reason would the nurse encourage a client to void during the first stage of labor? 1. A full bladder is often injured during labor. 2. A full bladder may inhibit the progress of labor. 3. A full bladder jeopardizes the status of the fetus. 4. A full bladder predisposes the client to urinary infection
2. A full bladder inhibits the progress of labor by encroaching on the uterine space and impeding the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.
Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation?
By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.
Which action would the nurse take when a client begins to shiver uncontrollably about 1 hour after giving birth?
Cover the client with blankets to alleviate this typical postpartum reaction. There are several theories about why chilling occurs; one is that it is caused by vasomotor instability resulting from fetus-to-mother transfusion during placental separation; comfort measures such as warm blankets or fluids are indicated. Although the vital signs should be monitored during the fourth stage of labor, they are not being monitored because of the shivering, which is an expected response to the birth. Changes in blood pressure are unexpected. Shivering is not a sign of dehydration.
An adolescent who gave birth 12 hours ago continually talks on the phone to her friends and does not respond when her new baby cries. Which is the priority intervention at this time?
Modeling appropriate behaviors that encourage infant bonding All women go through several phases of adapting to the role of mother. An adolescent may still need time to adjust to her new role, especially if she has just given birth in the past 24 hours. By modeling appropriate behavior, the nurse demonstrates appropriate maternal skills to the adolescent. This will assist her as she makes the transition into her new role as a mother. If this behavior continues and does not improve before discharge, social services may need to get involved, but a consult is not needed in this early phase. A psychiatric consult is not necessary because this is not a psychiatric illness. The adolescent's parent is an important part of the plan, especially if the adolescent is going home to her or his house, but the relationship between the two needs to be assessed to see what role he or she will play in this new parent-child relationship.
The nurse teaches a postpartum client how to care for her episiotomy 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. Washing the hands before and after every pad change prevents the transfer of microorganisms from the hands to the genital tract or vice versa. Changing the perineal pad twice daily is an inadequate number of changes; soiled pads promote the growth of microorganisms because they are warm and moist and provide a medium for growth. Rinsing the perineum with water after using an analgesic spray interferes with the analgesic action of the spray and does not prevent infection. Cleansing the perineum from the anus toward the symphysis pubis promotes contamination of the vagina and urethra by organisms from the perianal area.
When assessing frequency of contractions, the time is measured between which two events?
The complete relaxation of the uterus at the end of a contraction to the start of the next contraction Timing until the beginning of the next contraction is the accepted way of determining the frequency of contractions. The time between beginning of a contraction and the end of that contraction is the duration of the contraction. The end of one contraction to the start of the next contraction does not reflect the frequency, nor does the time from the complete relaxation of the uterus at the end of a contraction to the start of the next contraction.
On a routine prenatal visit, which is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time?
The recognition of fetal movement or quickening commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting is abnormal and requires immediate follow-up care.
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. Which conclusion is supported by this finding? 1. There is a slow rate of involution. 2. There are retained placental fragments. 3. The bladder has become distended. 4. The uterine ligaments are overstretched
3. A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions 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 regarding overstretched uterine ligaments.
Which instruction would the nurse include when teaching episiotomy care? 1. Rest with legs elevated at least 2 times a day. 2. Avoid stair climbing for several days after discharge. 3. Perform perineal care after toileting until healing occurs. 4. Continue sitz baths 3 times a day if they provide comfort
3. Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.
The nurse suspects a thrombus after assessing a client who has pain in her right calf 2 days after a cesarean birth. Which is the nurse's immediate action?
Confine client to bed. When a thrombus is suspected but before a definitive diagnosis is made, the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.
A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How would the nurse respond?
Explain why this is expected in early pregnancy. The client should be given accurate information. Urinary frequency is caused by the pressure of the enlarging uterus on the bladder. Until 12 to 14 weeks of pregnancy the uterus is in the pelvic cavity. It then rises into the abdominal cavity, after which urinary frequency diminishes. It is unnecessary to refer the client to the health care provider. Urinary frequency is an expected adaptation during the first and last trimesters of pregnancy. Telling the client not to worry is demeaning because it implies that the client is not capable of understanding an explanation. It is not necessary to plan for a culture and sensitivity testing because the routine point-of-care urinalysis performed at each visit will indicate whether an infection is present and whether culture and sensitivity testing are necessary
Information about which factor can be obtained by means of an amniocentesis done during the 16th week of gestation?
Neural tube defect Alpha-fetoprotein in amniotic fluid is increased in the presence of a neural tube defect. Lung maturity cannot be determined until after 35 weeks' gestation. Neither diabetes nor cardiac disorders can be detected with the use of amniocentesis.
Which is the priority nursing intervention for the postpartum client whose fundus is 3 fingerbreadths above the umbilicus, boggy, and midline? 1. Massaging the uterine fundus 2. Helping the client to the bathroom 3. Assessing the peri-pad for the amount of lochia 4. Administering intramuscular methylergonovine (Methergine) 0.2 mg
1. A uterus that is displaced and above the umbilicus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine (Methergine) is administered.
Which common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? 1. Intrusion on movement 2. Inability to take sedatives 3. Interference with breathing techniques 4. Increased frequency of vaginal examinations
1. Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.
Which laboratory finding on a client at 24 weeks' gestation would the nurse report to the health care provider?
Hemoglobin: 10.8 g/dL (108 mmol/L) The hemoglobin level of a healthy individual is 12 to 16 g/dL (120-160 mmol/L). During pregnancy it may decrease as a result of an increased blood volume, especially during the second trimester. The hemodilution is greater than a concomitant increase in red blood cell (RBC) production, causing physiological anemia. If the hemoglobin decreases to less than 11 g/dL (110 mmol/L), anemia, probably due to a deficiency of iron or folic acid, is diagnosed. Iron supplementation may need to be increased. The expected platelet level is 150,000 to 400,000 mm^3 (150 × 109/L to 400 × 109/L). There should be no significant change in this level throughout pregnancy. The expected fasting blood glucose is 70 to 105 mg/dL (3.9-5.8 mmol/L); it begins to rise in the second trimester and peaks in the third trimester. The white blood cell (WBC) count during pregnancy is 5000 to 15,000 mm^3. It begins to increase in the second trimester and peaks in the third.
For which reason is an ultrasound done during the first trimester? 1. Estimate fetal age 2. Detect hydrocephalus 3. Rule out congenital defects 4. Approximate fetal linear growth
1. Measurement of the crown-rump length 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.
Which suggestion would the nurse make to a client with morning sickness? 1. "Eat dry crackers before you get out of bed." 2. "Increase your fat intake before bedtime." 3. "Drink high-carbohydrate fluids with meals." 4. "Eat 2 small meals a day and a snack at noon."
1. 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 2 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 5 or 6 small meals daily instead of three large ones is helpful.
Which factor distinguishes true labor from false labor? 1. Cervical dilation is evident. 2. Contractions stop when the client walks around. 3. The client's contractions progress only when she is in a side-lying position. 4. Contractions occur immediately after the membranes rupture.
1. Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions will increase with activity. Contractions of true labor persist in any position. Contractions may not begin until 24 to 48 hours after the membranes rupture.
During a nonstress test, the baseline fetal heart rate of 130 to 140 beats per minute rises to 160 twice and 157 once during a 20-minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take? 1. Discontinue the test because the pattern is within the normal range. 2. Encourage the client to drink more fluids to decrease fetal heart rate. 3. Notify the primary health care provider and prepare for an emergency birth. 4. Record this nonreassuring pattern and continue the test for further evaluation.
1. The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.
Which information concerning the childbearing process would the nurse teach a client during the first trimester of pregnancy?
Physical and emotional changes resulting from pregnancy Increasing the client's knowledge of physical and emotional changes resulting from pregnancy prepares the client for expected changes as pregnancy continues; it is most effective when taught during the first trimester. It is too early to teach about labor and birth; this should be done in the last trimester. The client should be alerted to danger signs and symptoms; however, primary teaching is directed toward increasing her knowledge of expected physiological changes. Concerns about role transition to parenthood should be addressed in the third trimester.
Which direction would the nurse give a client in preparation for ultrasonography at the end of her first trimester? 1. Empty her bladder. 2. Avoid eating for 8 hours. 3. Take a laxative the night before the test. 4. Increase fluid intake for 1 hour before the procedure.
In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation, so directing the client to not eat for 8 hours before the test or to take a laxative would not be appropriate.
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. Which nursing action is an appropriate response to this situation? 1. Having the client empty her bladder 2. Watching for signs of retained secundines 3. Massaging the uterus vigorously to prevent hemorrhage 4. Explaining to the client that this is a sign of uterine stabilization
1, A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. The bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not accurate; the uterus will not remain contracted over a full bladder.
