SAUNDERS MATERNITY: Diabetes, Postpartum Uterine Problems, Hematoma ad Hemorrhage

A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse should anticipate that which treatment measure would most likely be prescribed next for the mother? 1.An oral hypoglycemic agent 2.A 3-hour glucose tolerance test 3.Humulin N insulin on a daily basis 4.A sliding-scale regular insulin dose

2.A 3-hour glucose tolerance test HomeHelpCalculator Study Mode Question 3 of 14 ID: 3071 | Fundamentals of Care_Diagnostic Tests_final.htm #3352 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse should anticipate that which treatment measure would most likely be prescribed next for the mother? Rationale:A maternal glucose level is done to screen for gestational diabetes. A 50-g oral glucose load may be prescribed and is followed by a serum glucose determination 1 hour later. If the test is done without regard for fasting, 140 mg/dL (8 mmol/L) is the upper limit of normal. If the test is done when the woman is fasting, the upper acceptable limit is 135 mg/dL (7.7 mmol/L). Clients exceeding these limits should be further evaluated with a 3-hour glucose tolerance test. The remaining options would not be prescribed based solely on the maternal glucose level. Further follow-up would be implemented. Test-Taking Strategy(ies):Note the strategic words, most likely and next. Eliminate options 1, 3, and 4 because they are comparable or alike in that they all identify the administration of medication to treat an elevated blood glucose level. The correct option is the only one that identifies further evaluation of the client.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1.A temperature of 100.4° F (38° C) 2.An increase in the pulse rate from 88 to 102 beats per minute 3.A blood pressure change from 130/88 to 124/80 mm Hg 4.An increase in the respiratory rate from 18 to 22 breaths per minute

2.An increase in the pulse rate from 88 to 102 beats per minute Rationale:During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal. Test-Taking Strategy(ies):Note the strategic word, early. Think about the physiological occurrences of hemorrhage and shock and the expected findings in the postpartum period. This should assist in directing you to the correct option.

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client? 1.Administer her prepregnancy dose of metformin. 2.Assess her blood glucose before administering any glucose-lowering medications. 3.Administer 20 units of long-acting insulin, as sufficient time has elapsed since delivery. 4.Keep NPO (nothing by mouth) for an additional 4 hours to allow the blood glucose to normalize.

2.Assess her blood glucose before administering any glucose-lowering medications. Rationale:Frequently, after delivery blood glucose is maintained for several days at a relatively low level, especially when the mother is breast-feeding, as the placental hormones have been depleted. It is not necessary to keep this mother NPO, and not feeding her may actually be harmful to her. No medications to alter her blood glucose should be administered to this mother without having assessment data about her current blood glucose level. Test-Taking Strategy(ies):Focus on the subject, maintaining euglycemia postdelivery. Eliminate administering oral hypoglycemic or parenteral hypoglycemic agents, as these are comparable or alike in that they will lower the blood glucose level. Next, eliminate keeping the mother NPO, as this also may make her hypoglycemic.

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock? 1. Complaints of abdominal cramping 2. An increased pulse rate of 80 to 120 beats/min 3. Complaints of feeling tired yet is feeling hungry 4. An increase in the respiratory rate from 18 to 22 breaths/min

2. An increased pulse rate of 80 to 120 beats/min Rationale:During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure is not the earliest sign of shock. An increase in the respiratory rate from 18 to 22 breaths/min is not a concern and is within normal range. Complaints of abdominal cramping, feeling tired, and feeling hungry is normal in the postpartum period.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs Rationale:Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues. Test-Taking Strategy(ies):Note the strategic word, best. Also note that the client received epidural anesthesia. With this in mind, eliminate options 3 and 4. From the remaining options, use the ABCs—airway, breathing, and circulation—to direct you to the correct option.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1.Forceps delivery 2.Schultz presentation 3.Hypotonic contractions 4.Weak bearing-down efforts

1.Forceps delivery Rationale:Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall. Test-Taking Strategy(ies):Focus on the subject, the risks associated with uterine rupture. Read each option carefully, and select the one that provides an additional source of pressure to the uterus and would be most likely to add to the risk of rupturing or "tearing" the uterus. The correct option is the only choice that would provide an additional source of pressure to the uterus.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? 1.The client's last baby weighed 10 pounds at birth. 2.The client's previous deliveries were by cesarean section. 3.The client has a family history of cardiovascular disease. 4.The client is 5 feet, 3 inches tall and weighs 165 pounds.

1.The client's last baby weighed 10 pounds at birth. Rationale:Known risk factors that increase the risk of developing gestational diabetes include obesity (more than approximately 198 pounds, depending on height), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (greater than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes. Test-Taking Strategy(ies):Focus on the subject, risk factors associated with development of gestational diabetes. Read each option carefully, and use knowledge regarding these risk factors to assist in directing you to the correct option.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Notify the obstetrician (OB). 3. Reassess the client in 2 hours. 4. Encourage increased oral intake of fluids.

2. Notify the obstetrician (OB). Rationale:Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the OB. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Focus on the words larger than 1 cm. Think about the significance of lochial clots in the postpartum period to answer correctly.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? 1.Uterine tone 2.Blood pressure 3.Amount of lochia 4.Deep tendon reflexes

2.Blood pressure Rationale:Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The obstetrician needs to be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, blood pressure is related specifically to the administration of this medication. Test-Taking Strategy(ies):Note the strategic word, priority. Eliminate options 1 and 3 first because they are comparable or alike and related to one another. To choose from the remaining options, use the ABCs—airway, breathing, and circulation. Blood pressure is a method of assessing circulation.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1.Elevate the client's legs. 2.Massage the fundus until it is firm. 3.Ask the client to turn on her left side. 4.Push on the uterus to assist in expressing clots

2.Massage the fundus until it is firm. Rationale:If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Test-Taking Strategy(ies):Focus on the subject, a soft and boggy uterus. Visualize the situation and recall the therapeutic management for uterine atony. Remember that a full bladder displaces the uterus.

The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." Rationale:To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes and the number of pads used also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the information also may not provide accurate data. Test-Taking Strategy(ies):Note the strategic word, most, and the word objective. Eliminate option 2 first because this choice relies on the client's interpretation of the amount of lochial flow. Next, eliminate estimating blood loss and gauging an amount of lochial flow because this does not provide accurate data.

The nurse in the postpartum unit notes that a new mother was given methylergonovine intramuscularly following delivery. What assessment finding indicates that the medication was effective? 1. Lochia that is serous 2. Normal blood pressure 3. Decreased uterine bleeding 4. Decreased uterine contractions

3. Decreased uterine bleeding Rationale:Methylergonovine, an oxytocic, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose usually is given intramuscularly; if additional medication is needed, it is given by mouth. No relationship exists between the action of this medication and lochial drainage. This medication may elevate the blood pressure and increase the strength and frequency of contractions. A priority assessment component before the administration of methylergonovine is blood pressure. Test-Taking Strategy(ies):Note the strategic word, effective, and focus on the subject, the intended effect of the medication. Recalling that methylergonovine is an oxytocic will direct you to the correct option.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the obstetrician. 2. Assess the client's vital signs. 3. Gently massage the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin solution.

3. Gently massage the uterine fundus. Rationale:The most frequent cause of excessive bleeding after childbirth is uterine atony. A major initial intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. In addition, a prescription is needed to administer a medication. Calling the obstetrician, assessing the client's vital signs, and administering a bolus of oxytocin may be necessary, but they are not initial actions. Test-Taking Strategy(ies):Focus on the strategic word, initial. Although all of the actions may be necessary, the nurse's immediate priority would be to attempt to restore uterine tone so as to decrease bleeding. Option 3 is the only intervention that could immediately affect the tone of the uterus.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the obstetrician (OB). 4. Place the client in Trendelenburg's position.

3. Notify the obstetrician (OB). Rationale:If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the OB. Test-Taking Strategy(ies):Note the strategic word, initial. Focus on the data in the question, noting the clinical manifestations identified in the question. Eliminate option 2 first because, if the uterus is firm, it would not be necessary to perform fundal massage. Knowing that Trendelenburg's position interferes with cardiac and respiratory function will assist in eliminating option 4. From the remaining options, noting the words bleeding is excessive will assist in directing you to the correct option.

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1.A primiparous client who delivered 4 hours ago 2.A multiparous client who delivered 6 hours ago 3.A multiparous client who delivered a large baby after oxytocin induction 4.A primiparous client who delivered 6 hours ago and had epidural anesthesia

3.A multiparous client who delivered a large baby after oxytocin induction Rationale:The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage. Test-Taking Strategy(ies):Note the strategic word, most. Focus on the subject, the client at most risk for hemorrhage. Read the client description in each option. Noting the words large and oxytocin in the correct option will direct you to this option.

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation? 1.The client is hemorrhaging. 2.The client needs to increase oral fluids. 3.The client is experiencing normal lochia discharge. 4.The client's primary health care provider (PHCP) needs to be notified of the finding.

3.The client is experiencing normal lochia discharge. Rationale:Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the client is not hemorrhaging, not in need of increased fluids, and there is no need to contact the PHCP. Test-Taking Strategy(ies):Focus on the data in the question to assist in answering. Hemorrhaging and contacting the PHCP can be eliminated first because they are comparable or alike. If the client is hemorrhaging, the PHCP would need to be notified. Regarding the remaining choices, noting the words immediate postpartum period in the question will help you to realize that the client is experiencing normal lochia discharge.

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area.

4. Prepare an ice pack for application to the area. Rationale:A hematoma is a localized collection of blood in the tissues of the reproductive tissues after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent. Test-Taking Strategy(ies):Focus on the subject, a small vulvar hematoma. Think about the effect of each action in the options; this focus will assist in directing you to the correct option.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the primary health care provider (PHCP), what is the nurse's next action? 1.Reassure the client. 2.Monitor fundal height. 3.Apply perineal pressure. 4.Prepare the client for surgery.

4.Prepare the client for surgery. Rationale:A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The use of an epidural, prolonged second-stage labor, and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 mL of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action is to prepare the client for surgery to stop the bleeding. Test-Taking Strategy(ies):Note the strategic word, next. Focus on the data in the question to determine that the bleeding needs to be stopped. This will direct you to the correct option.

The nurse should take which nursing actions when caring for a postpartum client who begins to hemorrhage? Select all that apply. 1.Assess for uterine atony: 2.Prepare to administer blood or blood products as prescribed. 3.Insert an indwelling urinary catheter to monitor kidney perfusion. 4.Administer 8 to 10 L/min of oxygen via non-rebreather face mask. 5.Administer uterotonic medications as prescribed to increase uterine tone.

1, 2, 3, 4, 5 Rationale:In the postpartum client, if bleeding is excessive and signs of shock are evident, the nurse immediately contacts the primary health care provider (PHCP) because this is a life-threatening situation. The nurse never leaves a client who is unstable or experiencing a life-threatening condition and would ask another nurse to contact the PHCP. The nurse should quickly attempt to determine the cause of the hemorrhage, and if the client is experiencing uterine atony, the nurse should massage the uterus gently to cause it to contract (do not push on an uncontracted uterus). The nurse positions the client to assist in perfusion of body organs; implements prescriptions, including oxygen administration; and monitors vital signs. Medications to contract the uterus, fluids to restore circulating blood volume, and blood replacement therapy may be prescribed in addition to other emergency medications. Surgical intervention may be required if the bleeding is caused by a laceration or retained placental fragments. The nurse then records the event, the interventions instituted, and the client's response to interventions. Test-Taking Strategy(ies):Focus on the subject, a postpartum client who begins to hemorrhage. Then think about the pathophysiology of postpartum hemorrhage. You must know what the most common causes of postpartum hemorrhage are to be able to answer this question correctly. Each option displays correct information about interventions that should be implemented when caring for a client with postpartum hemorrhage.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? 1."A fever on and off is expected and is nothing to worry about." 2."Even though I am breast-feeding my baby, I still can ovulate." 3."I can begin abdominal exercises about a month after delivery." 4."I should contact my doctor if I am having any feelings of depression."

1."A fever on and off is expected and is nothing to worry about." Rationale:A fever in the postpartum period is not expected, and if this occurs the client should contact the primary health care provider because fever is an indication of infection. Women may ovulate in the postpartum period even without menstruating, so breast-feeding should not be considered a form of birth control. Abdominal exercises should not start until 3 to 4 weeks after abdominal surgery to allow for healing of the incision. Postpartum depression is a concern, and the client should contact her primary health care provider if she is having any depressed feelings. Test-Taking Strategy(ies):Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Keep in mind that the client had a cesarean delivery. Noting the word fever in option 1 will assist in directing you to this option.

During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? 1."Diet and insulin needs change during pregnancy." 2."I will plan my diet based on the results of urine glucose testing." 3."I will need to eat 600 more calories every day because I am pregnant." 4."I can continue with the same diet as before pregnancy, as long as it is well balanced."

1."Diet and insulin needs change during pregnancy." Rationale:The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. An increase of 600 calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the second and third trimesters, insulin needs increase. Test-Taking Strategy(ies):Note the strategic word, effective. Use knowledge of the dietary needs and management of a pregnant client with diabetes mellitus. Note that the correct choice is the umbrella option and is a general statement.

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1."I will begin abdominal exercises immediately." 2."I will notify the primary health care provider if I develop a fever." 3."I will turn on my side and push up with my arms to get out of bed." 4."I will lift nothing heavier than my newborn baby for at least 2 weeks."

1."I will begin abdominal exercises immediately." Rationale:A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Keeping in mind that the client had a cesarean delivery and noting the word immediately in the correct option will assist in directing you to this option.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1."I will need to increase my insulin dosage during the first 3 months of pregnancy." 2."My insulin dose will likely need to be increased during the second and third trimesters." 3."Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4."My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1."I will need to increase my insulin dosage during the first 3 months of pregnancy." Rationale:Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy. Test-Taking Strategy(ies):Note the strategic words, further teaching is needed. These words indicate a negative event query and the need to select an incorrect client statement. Eliminate options 2, 3, and 4 because they are comparable or alike and are accurate statements. Remember that insulin needs decrease in the first trimester of pregnancy.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse should provide the client with which information? 1.Glucose crosses the placenta 2.Insulin crosses the placenta 3.Increased caloric intake is needed 4.Decreased caloric intake is required

1.Glucose crosses the placenta Rationale:Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin and is referred to as the diabetogenic effect of pregnancy. Caloric requirements are not affected by diabetes. Test-Taking Strategy(ies):Focus on the subject, insulin needs for a diabetic pregnant client. Use specific knowledge of the pathophysiology associated with diabetes to assist you in answering the question. Eliminate caloric intake options first because diabetes does not change caloric requirements. Recall that the need for insulin may decrease in the first half of pregnancy and increase in the second half of pregnancy and that glucose crosses the placenta, but insulin does not to assist you in answering correctly.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? 1.Increased insulin 2.Decreased insulin 3.Increased caloric intake 4.Decreased protein intake

1.Increased insulin Rationale:Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric and protein intake is not affected by diabetes. Test-Taking Strategy(ies):Focus on the subject, treatment for diabetes mellitus in the pregnant client in the second half of pregnancy. Use knowledge regarding the pathophysiology associated with diabetes mellitus to assist in answering the question. Eliminate "increased caloric intake" and "decreased protein intake" first because diabetes mellitus does not change caloric or protein needs. Recalling that the need for insulin may decrease in the first half of pregnancy and increase in the second half of pregnancy will direct you to the correct option.

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1.Massaging the uterus 2.Pushing gently on the uterus 3.Assisting the woman to urinate 4.Rechecking the uterus in 1 hour 5.Checking for a distended bladder 6.Calling the delivery room to schedule an abdominal hysterectomy

1.Massaging the uterus 3.Assisting the woman to urinate 5.Checking for a distended bladder Rationale:If the uterus is soft and spongy and not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse should then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert it, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in excessive blood loss. The primary health care provider (PHCP) will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. In addition, the nurse should not schedule an operative procedure. Test-Taking Strategy(ies):Focus on the subject, a uterus that is soft and spongy, to assist you in selecting the correct interventions. Eliminate option 6 because the nurse would not schedule a surgical procedure without prescriptions from the PHCP. Next, eliminate option 2 because of the word pushing and option 4 because waiting an hour could delay necessary intervention. In addition, recalling the causes and consequences of an uncontracted uterus will assist you in answering the question.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs? 1.Afterpains 2.Retained placental fragments from delivery 3.An oral temperature of 99.0º F (37.2º C) following delivery 4.Increased estrogen and progesterone levels as noted on laboratory analysis

2.Retained placental fragments from delivery Rationale:Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. The presence of afterpains and a temperature of 99.0º F (37.2º C) after delivery are expected findings. Hormonal levels are not a cause of subinvolution and are unrelated to the subject of the question. Test-Taking Strategy(ies):Note the strategic word, most, and the subject, findings in subinvolution. Eliminate afterpains and a slight increase in temperature first because these are expected findings after delivery. Regarding the remaining options, focus on the anatomical location of the disorder. This will assist in directing you to the correct option.

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply. 1.Afterpains 2.Uterine infection 3.Increased estrogen levels 4.Increased progesterone levels 5.Retained placental fragments from delivery

2.Uterine infection 5.Retained placental fragments from delivery Rationale:Infections and retained placental fragments are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Hormonal levels are not causes of subinvolution. Test-Taking Strategy(ies):Focus on the subject, subinvolution. Focusing on the pathophysiology of subinvolution will direct you to the correct options.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1."I should stay on the diabetic diet." 2."I should perform glucose monitoring at home." 3."I should avoid exercise because of the negative effects on insulin production." 4."I should be aware of any infections and report signs of infection immediately to my obstetrician."

3."I should avoid exercise because of the negative effects on insulin production." Rationale:Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician. Test-Taking Strategy(ies):Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select an incorrect client statement. Also, noting the closed-ended word "avoid" in the correct option will assist in answering the question.

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client? 1."Your OGTT results indicate that your baby is at high risk for macrosomia, and special considerations may be necessary at delivery." 2."Your OGTT results are within normal limits, but continuing your prenatal visits remains essential to monitor fetal growth and development." 3."The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." 4."Your OGTT results indicate that you are positive for gestational diabetes. You will be scheduled for a dietitian consultation to plan your daily dietary intake."

3."The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." Rationale:Recommendations for gestational diabetes mellitus (GDM) screening during pregnancy indicate that women should be screened using the 1-hour OGTT at 24 to 28 weeks' gestation. The OGTT is a screening tool, and when results are greater than 140 mg/dL (8 mmol/L) the recommendation is further assessment via the 3-hour OGTT. Although fetal macrosomia is associated with maternal glucose intolerance, this diagnosis cannot be made with a 1-hour OGTT, thus eliminating option 1. Option 2 indicates that the OGTT results are within normal limits and therefore can be eliminated because the client's 1-hour OGTT results exceed the normal level. Only when 2 or more of the 4 measured glucose levels are exceeded can a woman be diagnosed with GDM. This fact eliminates option 4. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, the 1-hour OGTT. Knowing that the laboratory result is elevated will direct you to the correct option. When the laboratory result is elevated, further evaluation is needed.

The nurse suspects the presence of uterine atony and massages the uterus, but this action does not assist in controlling blood loss. Which is the next nursing action? 1.Take the client's blood pressure. 2.Measure the amount of drainage on the peripad. 3.Contact the primary health care provider (PHCP). 4.Ask the blood bank to prepare a unit of blood for the client.

3.Contact the primary health care provider (PHCP). Rationale:When uterine atony occurs, the initial nursing action should be to massage the uterus until it is firm. If this does not assist in controlling blood loss, the nurse should contact the PHCP. In addition, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss. Blood administration needs to be prescribed by the PHCP. Test-Taking Strategy(ies):Note the strategic word, next. Also, focusing on the word atony and the data in the question will direct you to the correct option.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? 1.Presence of dark red lochia 2.Palpation of the uterus as a firm, contracted ball 3.The saturation of more than 1 peripad per hour 4.Palpation of the fundus at the level of the umbilicus

3.The saturation of more than 1 peripad per hour Rationale:Saturation of more than 1 peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount. Test-Taking Strategy(ies):Focus on the subject, a complication related to a laceration of the birth canal. Eliminate the options that indicate normal physiological findings in the fourth stage of labor. Noting the word saturation in the correct choice will assist in directing you to this option.

The nurse has determined that a postpartum client has uterine atony. The nurse should take actions in which priority order? Arrange the actions in the priority order that they should be done. All options must be used. 1.Monitor vital signs 2.Contact the primary health care provider 3.Check the amount of drainage on the peripad. 4.Massage the uterus attempting to achieve firmness.

4, 2, 1, 3 Rationale:When uterine atony occurs, the first nursing action would be to massage the uterus until firm. If this does not assist in controlling blood loss, the primary health care provider is notified. In addition, once bleeding is under control, the nurse should monitor the vital signs and then estimate the amount of blood loss. Test-Taking Strategy(ies):Note the strategic word, priority. Focus on the data in the question, that the client has uterine atony. Specific knowledge regarding this complication will direct you to selecting massaging as the first intervention. Remember that if massage does not assist in controlling blood loss, the primary health care provider is notified. Next use the ABCs-airway, breathing, and circulation-to select between the remaining options. Remember vital signs reflect airway, breathing, and circulation.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1. Chest pain 2. A rigid abdomen 3. A soft and boggy uterus 4. Complaints of severe abdominal pain

4. Complaints of severe abdominal pain Rationale:Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting. Test-Taking Strategy(ies):Focus on the subject, signs of uterine inversion. Note the strategic word, immediate. Reading each option carefully and recalling the pathophysiology associated with uterine inversion will assist you in answering correctly. Remember that severe abdominal pain is a sign of uterine inversion.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates an understanding of self-care for this diagnosis? 1."I need to eat fruits and vegetables only." 2."I will go to the laboratory daily for a glucose test." 3."I cannot exercise because of the negative effects on insulin production." 4."I will report signs of infection immediately to my primary health care provider."

4."I will report signs of infection immediately to my primary health care provider." Rationale:Signs of infection need to be reported immediately to the primary health care provider because of the risk of complications. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet that is balanced with all food groups. Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Many women are taught to perform blood glucose monitoring. If the woman is not performing the blood glucose monitoring at home, it is not necessary for the woman to report to the laboratory daily for a blood test. Test-Taking Strategy(ies):Focus on the subject, an understanding of self-care for gestational diabetes mellitus. Eliminate option 1 because of the closed-ended word "only." Next, eliminate option 2 because of the word daily. To select from the remaining options, recall that exercise has positive effects and think about the complications that can occur if an infection presents.

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1."I will probably need my mother to help me with housekeeping." 2."Because I am so sore, I will nurse the baby while lying on my side." 3."My husband and I will not have intercourse until the stitches are healed." 4."The only medications I will take are prenatal vitamins and stool softeners."

4."The only medications I will take are prenatal vitamins and stool softeners." Rationale:A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The postoperative client will need an antibiotic because she is at increased risk for infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will need only prenatal vitamins and stool softeners indicates that she requires further teaching. All other options indicate that the mother understands the home care measures after surgical evacuation and repair of a paravaginal hematoma. Test-Taking Strategy(ies):Note the strategic words, needs further discharge instructions. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that the client is at increased risk for infection because of the break in skin integrity and collection of blood at the hematoma site will direct you to the correct option because antibiotics will be needed.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1.Provide oral fluids and begin fundal massage. 2.Begin hourly pad counts and reassure the client. 3.Elevate the head of the bed and assess vital signs. 4.Assess for hypovolemia and notify the primary health care provider (PHCP).

4.Assess for hypovolemia and notify the primary health care provider (PHCP). Rationale:Symptoms of hypovolemia include cool, clammy, pale skin; sensations of anxiety or impending doom; restlessness; and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the PHCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition. Test-Taking Strategy(ies):Note the strategic word, immediate, and focus on the data in the question. Use the steps of the nursing process to select the correct option. The correct choice is the only option that addresses assessment.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1.Peripads 2.Tape measure 3.Reflex hammer 4.Blood pressure cuff

4.Blood pressure cuff Rationale:Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure also should be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension occurs. Peripads, a tape measure, and a reflex hammer are not priority items. Test-Taking Strategy(ies):Note the strategic word, priority. Use the ABCs-airway, breathing, and circulation-to assist you in selecting the correct option.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1.Document the finding. 2.Encourage the client to ambulate. 3.Encourage the client to increase fluid intake. 4.Contact the obstetrician (OB) and inform him or her of this finding.

4.Contact the obstetrician (OB) and inform him or her of this finding. Rationale:Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized. Test-Taking Strategy(ies):Note the strategic word, initially. Focus on the data in the question, a saturated perineal pad in 15 minutes. Next, determine if an abnormality exists. The data and the use of guidelines determine the amount of lochial flow will help you determine that this is abnormal and warrants notification of the OB.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1.Document the finding. 2.Encourage the client to ambulate. 3.Encourage the client to increase fluid intake. 4.Contact the primary health care provider (PHCP) and inform the PHCP of this finding.

4.Contact the primary health care provider (PHCP) and inform the PHCP of this finding. Rationale:Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the PHCP in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized. Test-Taking Strategy(ies):Note the strategic word, initially. Focus on the data in the question, a saturated perineal pad in 15 minutes. Next, determine if an abnormality exists. The data and the use of guidelines to determine the amount of lochial flow will help you to determine that this is abnormal and warrants notification of the PHCP.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. 1.Back pain 2.Heavy vaginal bleeding 3.Increase in fundal height 4.Hard, board-like abdomen 5.Persistent abdominal pain 6.Early deceleration on the fetal heart monitor

4.Hard, board-like abdomen 5.Persistent abdominal pain Rationale:The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; hard, board-like abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding. Test-Taking Strategy(ies):Focus on the subject, signs of concealed bleeding. Noting the words concealed bleeding will assist you in eliminating option 2. Regarding the remaining options, focus on the subject and the pathophysiology associated with concealed bleeding to assist in directing you to the correct options.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history? 1.Hypotension 2.Hypothyroidism 3.Diabetes mellitus 4.Peripheral vascular disease

4.Peripheral vascular disease Rationale:Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids. Test-Taking Strategy(ies):Focus on the subject, the purpose, action, and contraindications of methylergonovine. Recalling that ergot alkaloids produce vasoconstriction will direct you to the correct option.

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. 1.Plan induction at 35 weeks. 2.Plan amniocentesis at this time. 3.Schedule a biophysical profile immediately. 4.Plan for weekly nonstress tests at 32 weeks. 5.Obtain nutritional counseling with a dietitian.

4.Plan for weekly nonstress tests at 32 weeks. 5.Obtain nutritional counseling with a dietitian. Rationale:Gestational diabetes can result in delayed lung maturity and complications, and carrying the baby until full term is the goal. The nurse should discuss nonstress testing procedures, the plan for nutritional counseling, and the plan for delivery. Amniocentesis is not indicated at this time. Biophysical profile is done at 32 to 36 weeks' gestation. Test-Taking Strategy(ies):Focus on the subject, care of the client diagnosed with gestational diabetes. Noting the time frames in the incorrect choices will assist in eliminating these options. In addition, recall that amniocentesis is not indicated at 29 weeks' gestation.

Which data places the client at risk for developing gestational diabetes during pregnancy? 1.The client has a family history of type 1 diabetes. 2.The client is 5 feet tall and weighs 129 lb. 3.The client's previous deliveries were by cesarean section. 4.The client has a history of gestational diabetes with her previous pregnancy.

4.The client has a history of gestational diabetes with her previous pregnancy. Rationale:Known risk factors that increase the risk of developing gestational diabetes include obesity (more than 198 lb), chronic hypertension, family history of type 2 diabetes, previous birth of a large infant (more than 4000 g), and gestational diabetes in a previous pregnancy. The other options are not risk factors associated with the development of gestational diabetes. Test-Taking Strategy(ies):Focus on the subject, risk factors associated with the development of gestational diabetes. Use the knowledge of these risk factors to assist in directing you to the correct option. Remember that the previous birth of a large infant and a history of gestational diabetes are risk factors.