Pregnancy-low risk NCO

When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? 1. There is a slow rate of involution. 2. There are retained placental fragments. 3. The bladder has become overdistended. 4. The uterine ligaments are overstretched.

3. the bladder has become overdistended Rationale: A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow 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.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? 1. First 2. Second 3. Prodromal 4. Transitional

1. first Rationale: The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

What is the best advice a nurse can provide to a pregnant woman in her first trimester? 1. "Cut down on drugs, alcohol, and cigarettes." 2. "Avoid drugs and don't smoke or drink alcohol." 3. "Avoid smoking, limit alcohol consumption, and don't take aspirin." 4. "Take only prescription drugs, especially in the second and third trimesters."

2. avoid drugs and don't smoke or drink alcohol Rationale: The first trimester is the period when all major embryonic organs are forming; drugs, alcohol, and tobacco may cause major defects. Cutting down on these substances is insufficient; they are teratogens and should be eliminated. Even 1 oz of an alcoholic drink is considered harmful; baby aspirin may be prescribed to some women who are considered at risk for pregnancy-induced hypertension; however, not during the first trimester. Medications, unless absolutely necessary, should be avoided throughout pregnancy; however, the first trimester is most significant.

During her first prenatal visit the client reports that her last menstrual period began on April 15. According to Nägele rule, what is the expected date of delivery (EDD)? 1. January 8 2. January 22 3. February 8 4. February 22

2. january 22 Rationale: To determine EDD with the use of Nägele rule, subtract 3 months from the date of the last menstrual period and add 7 days. January 8 is 2 weeks too early according to this formula. February 8 is too late. February 22 would be 1 month past the true EDD.

What is the optimal nursing intervention to minimize perineal edema after an episiotomy? 1. Applying ice packs 2. Offering warm sitz baths 3. Administering aspirin as needed (prn) 4. Elevating the hips on a pillow

1. applying ice packs Rationale: Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do? 1. Breathe into her cupped hands 2. Pant during the next three contractions 3. Hold her breath with the next contraction 4. Use a fast, deep, or shallow breathing pattern

1. breathe into her cupped hands Rationale: Dizziness and tingling of the hands are signs of respiratory alkalosis, most likely the result of hyperventilating. Breathing into cupped hands or a paper bag promotes the rebreathing of carbon dioxide. Panting during the next three contractions could cause the client to hyperventilate more. Holding her breath with the next contraction will not improve the client's respiratory alkalosis. Using a fast, deep, or shallow breathing pattern could cause the client to hyperventilate more.

During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent? 1. Fetal hypoxia 2. Perineal lacerations 3. Carpopedal spasms 4. Maternal hypertension

1. fetal hypoxia Rationale: Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time? 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. having the client empty her bladder Rationale: 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. Therefore 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.

What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline? 1. Massaging the uterine fundus 2. Helping the client to the bathroom 3. Assessing the peripad for the amount of lochia 4. Administering intramuscular methylergonovine (Methergine) 0.2 mg

1. massaging the uterine fundus Rationale: A uterus that is displaced and above the fundus 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 is administered.

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action? 1. Notifying the healthcare provider 2. Resuming continuous fetal heart monitoring 3. Continuing to monitor the maternal vital signs 4. Documenting the fetal heart rate as an expected response to contractions

1. notifying the healthcare provider Rationale: Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring 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. The expected FHR is 110 to 160 beats/min between contractions.

Which cervical changes are observed during pregnancy? Select all that apply. 1. The cervical tip becomes soft. 2. The fragility of cervical tissues decreases. 3. The volume of cervical muscles increases. 4. The external cervical os appears as a jagged slit. 5. The elasticity of cervical collagen-rich connective tissue increases.

1. the cervical tip becomes soft 3. the volume of cervical muscles increases 5. the elasticity of cervical collagen-rich connective tissue increases Rationale: By the beginning of the sixth week of pregnancy, the cervical tip softens. During pregnancy, the cervical muscles 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, not during pregnancy.

A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the patient at this time? 1. The cervix dilates and becomes effaced in true labor. 2. Bloody show is the first sign of true labor. 3. The membranes rupture at the beginning of true labor. 4. Fetal movements lessen and become weaker in true labor.

1. the cervix dilates and becomes effaced in true labor Rationale: 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 information should the nurse include in the discharge teaching of a postpartum client? 1. The prenatal Kegel tightening exercises should be continued. 2. The episiotomy sutures will be removed at the first postpartum visit. 3. She may not have a bowel movement for up to a week after the birth. 4. She should schedule a postpartum checkup as soon as her menses returns.

1. the prenatal kegel tightening exercises should be continued Rationale: 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.

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? 1. Turn her onto her left side 2. Elevate the head of the bed 3. Place her feet on several pillows 4. Give her oxygen via a face mask

1. turn her onto her left side Rationale: The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase blood pressure. Raising the head of the bed will not relieve uterine compression of the large vessels. Elevating the feet will not relieve uterine compression of the large vessels. Oxygen administration will not relieve uterine compression of the large vessels.

A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? 1. Increasing the infusion rate 2. Checking for a distended bladder 3. Continuing to perform fundal massage 4. Continuing to assess the blood pressure

2. checking for a distended bladder Rationale: A displaced and boggy uterus is usually the result of a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus. If still boggy, the uterus should be massaged until firm. The oxytocin infusion may need to be increased if voiding and fundal massage are ineffective; however, the healthcare provider must be notified to change the order. Continuing to perform fundal massage is necessary if the fundus remains boggy after the client has voided. Continuing to assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the priority.

A client in her 37th week of gestation calls the nurse at the clinic and reports, "My ankles are so swollen." Which intervention should the nurse recommend? 1. Limiting fluid intake during the day 2. Elevating her legs more frequently during the day 3. Restricting salt intake for the remainder of her pregnancy 4. Taking a mild diuretic that the healthcare provider will prescribe

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

The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment? 1. Drink fluids 2. Empty her bladder 3. Perform the Valsalva maneuver 4. Assume the semi-Fowler position

2. empty her bladder Rationale: Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side. There is no need to drink fluids before this assessment; however, the client should drink at least 2 L of fluid a day during the postpartum period. The Valsalva maneuver has no effect on the assessment of fundal height. Assessing the fundus while the client is in the semi-Fowler position will result in an inaccurate assessment. The bed should be flat, and the client should assume the supine position.

The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? 1. Clear, dark amber colored, and containing shreds of mucus 2. Straw-colored, clear, and containing little white specks 3. Milky, greenish yellow, and containing shreds of mucus 4. Greenish yellow, cloudy, and containing little white specks

2. straw colored, clear, and containing little white specks Rationale: By 36 weeks' gestation, amniotic fluid should be pale yellow 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.

The postpartum nurse is delegating tasks to an unlicensed health care worker. Which task should the nurse delegate? 1. Evaluation of a postpartum client's lochia 2. Vital signs on a client 4 hours after delivery 3. Assessment of a postpartum client's episiotomy 4. Assisting the postpartum client to breastfeed for the first time

2. vital signs on a client 4 hours after delivery Rationale: Evaluating the client's lochia, assessing the client's episiotomy, and helping the client breastfeed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery.

A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she has begun leaking breast milk. What is the best response? 1. She needs to come in for a calcium level. 2. She needs to come in for a nonstress test. 3. She needs to get off her feet and rest more. 4. This can be a normal occurrence during pregnancy.

4. this can be a normal occurrence during pregnancy Rationale: Many women begin to leak breast milk (colostrum) during pregnancy. This may occur during the third trimester. It is completely normal, and there is no issue with her health or the pregnancy. The woman just needs to purchase breast pads to absorb the milk.

A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part? 1. Entering the vagina 2. Floating within the bony pelvis 3. At the level of the ischial spines 4. Above the level of the ischial spines

3. at the level of the ischial spines Rationale: The ischial spines are used as landmarks in relation to the fetus's head, because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines. When the head enters the vagina it is below the ischial spines and its position is designated with positive numbers (+1 to +4). When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (-1 to -4).

During an emergency birth the fetal head is crowning on the perineum. How should the nurse support the head as it is being delivered? 1. By applying suprapubic pressure 2. By placing a hand firmly against the perineum 3. By distributing the fingers evenly around the head 4. By maintaining pressure against the anterior fontanel

3. by distributing fingers evenly around the head Rationale: 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.

A client in active labor starts screaming, "The baby is coming! Do something!" What is the nurse's primary action? 1. Notifying the practitioner of the imminent birth 2. Telling the client that it is too soon and encouraging her to pant 3. Checking the perineal area for the presenting part 4. Helping the client hold her knees together and explaining what to expect

3. checking the perineal area for the presenting part Rationale: The primary action by the nurse should be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse should remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.

A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What should the nurse do first? 1. Give her the bedpan. 2. Change the bed linens. 3. Inspect her perineal area. 4. Take an oral temperature.

3. inspect her perineal area Rationale: Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? 1. Kidney defects 2. Cardiac anomalies 3. Neural tube defects 4. Urinary tract anomalies

3. neural tube defects Rationale: The alpha-fetoprotein test can detect not only neural tube defects, but also 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.

The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first? 1. Notify the practitioner. 2. Elevate the head of the bed. 3. Reposition her on her left side. 4. Administer oxygen by way of face mask.

3. reposition her on her left side Rationale: Late decelerations may indicate impaired placental profusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the practitioner is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.

At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question? 1. Usually fluctuate in length 2. Continuous, without relaxation 3. Related to time of membrane rupture 4. Accompanied by progressive cervical dilation

4. accompanied by progressive cervical dilation Rationale: Progressive cervical dilation is the only positive sign of true labor; the cervix dilates in response to regular, coordinated uterine contractions. The contractions of true labor increase in length and intensity. A continuous contraction may have an adverse effect on the fetus; immediate intervention is required. The membranes may rupture before contractions begin; more frequently they rupture after true labor is established.

A client who expected to use the Lamaze technique throughout labor has an emergency cesarean birth. Two days later the client is found crying and tells the nurse that she is extremely disappointed because a cesarean birth was necessary. She asks the nurse why this happened to her. The nurse answers based upon which physiologic response? 1. The client's feelings will pass once she has bonded with her newborn. 2. The client is probably suffering from postpartum depression and needs special care. 3. An emergency cesarean birth affects a woman's self-concept, and the client's statement reflects this. 4. An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience.

4. an emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience Rationale: The client's response is appropriate to the situation; she is in the "Why me?" stage of the grieving process as she grieves over the loss of her anticipated birth experience. The client's feelings are unrelated to bonding. The client's statement is not indicative of depression. Self-concept is not specifically affected, although feelings of inadequacy are commonly expressed throughout the grieving process.

A client is scheduled for a nonstress test in the 37th week of gestation. The nurse explains the procedure. Which statement demonstrates that the client understands the teaching? 1. "I'll need to have an IV 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."

4. if the heart reacts well, my baby should do ok when i give birth Rationale: 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.

A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.8 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response? 1. "You have not gained enough weight. Can you increase your daily intake of calories?" 2. "Your weight is not a concern. I'll refer you to the dietitian, who will review your diet." 3. "You've gained too much weight for 23 weeks' gestation. Are your rings getting tight?" 4. "Your weight is expected for someone at 23 weeks' gestation. Continue your current diet."

4. your weight is expected for someone at 23 weeks' gestation. continue your current diet The recommended average weight gain is 2.2 to 5.5 lb (1 to 2.5 kg) during the first 12 weeks, then approximately 1 lb (0.45 kg) per week until birth; 14 to 16 lb (6.4 to 7.3 kg) is an appropriate weight gain at 23 weeks' gestation. Stating that the client has not gained enough weight is inaccurate information. Stating that the weight is not a concern dismisses the client's concern; also, the nurse is abdicating the responsibility for teaching by the referral to the dietitian. Stating that the client has gained too much weight for 23 weeks' gestation is inaccurate information that may produce anxiety. It implies that the client may have preeclampsia.