Antepartum/Intrapartum
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1."Come to the clinic immediately." 2."The vaginal discharge may be bothersome, but is a normal occurrence." 3."Report to the emergency department at the maternity center immediately." 4."Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."
"The vaginal discharge may be bothersome, but is a normal occurrence."
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1.Strict bed rest is required after the procedure. 2.Hospitalization is necessary for 24 hours after the procedure. 3.An informed consent needs to be signed before the procedure. 4.A fever is expected after the procedure because of the trauma to the abdomen.
.An informed consent needs to be signed before the procedure.
The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Positive pregnancy test 5.Fetal heart rate detected by a nonelectronic device 6.Outline of fetus via radiography or ultrasonography
1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Positive pregnancy test
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2.Check the mother's heart rate. 3.Notify the obstetrician (OB). 4.Tell the client that the fetal heart rate is normal.
3 The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Chadwick's sign C. Positive pregnancy test D. Amenorrhea
A. Palpable fetal movement Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1.A normal test result 2.An abnormal test result 3.A high risk for fetal demise 4.The need for a cesarean section
A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate
A nurse is caring for a client in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take? Instruct the client to pant during contractions Position the client supine with legs elevated Encourage client to soak in warm bath Apply pressure to clients sacral area during contractions
Apply pressure to clients sacral area during contractions Provides counterpressure which lifts fetal head away from sacral nerves, decreasing pain
A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rho(D) immune globulin B. Request a prescription for an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that she will need to deliver via cesarean birth
C. Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery. Incorrect Answers: A. This client has Rh-negative blood and should have received Rho(D) immune globulin at 28 weeks gestation. She should receive it again within 72 hours if the newborn is Rh-positive. B. The client will receive IV antibiotic therapy during labor to prevent the transmission of group B beta-hemolytic streptococcus to the newborn. D. The client has no laboratory findings that warrant delivery by cesarean birth.
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? A. Ensure the client has a full bladder B. Stand at the client's right side if the nurse is right-handed C. Assist the client onto her back with knees extended. D. Palpate the outline of the fetus's head with the palms of the hands
Correct Answer: B. Stand at the client's right side if the nurse is right-handed The nurse should stand facing the client on the side that correlates with the nurse's dominant hand; therefore, if the nurse is right-handed, the nurse should stand at the client's right side. Incorrect Answers: A. The nurse should assist the client to empty her bladder prior to performing Leopold maneuvers. C. Placing the client in a supine position increases the risk of supine hypotension; therefore, the nurse should place a pillow under the client's head and a rolled towel under her hip with the knees flexed. D. The nurse should palpate the outline of the fetus's head with the fingertips
A nurse is caring for a client who is pregnant and whose last menstrual period (LMP) began on April 8. Using Naegele's rule, which of the following dates would be the client's estimated date of birth (EDB)? A. July 15 B. July 11 C. January 11 D. January 15
Correct Answer: D. January 15 According to Naegele's rule, the nurse should subtract 3 months and add 7 days to the first day of the client's LMP to determine the EDB, plus or minus 7 days. April (month 4) minus 3 months yields January. After adding 7 days to the date of the client's LMP, the EDB is January 15.
A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take? A. Have the client watch a video on fetal growth and development during pregnancy. B. Supply pamphlets that discuss the importance of nutrition during pregnancy. C. Explain how poor nutrition can prevent the baby from growing properly. D. Provide examples of how eating well will help maintain a healthy weight during pregnancy.
D Adolescents are typically preoccupied with self and lack the ability to understand outcomes that will occur in the future. Effective teaching for this age group should mainly focus on benefits to the client and positive outcomes that will occur in the near future.
A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? A. "My ankles are swollen at the end of the day." B. "I can feel the baby kicking my ribs, and it is very uncomfortable." C. "I'm growing more and more worried every day." D. "My heart feels like it is racing."
D. The nurse should assess the client's heart rate. The primary action of terbutaline involves bronchodilation and relaxation of smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified.
A nurse is teaching a client who is in labor about the use of nitric oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? Nitrous oxide could make my baby sleepy when born I should inhale nitrous oxide between contractions I will feel the effects of the nitrous oxide almost immediately Nitrous oxide can make me feel disoriented
I will feel the effects of the nitrous almost immediately A. Nitrous oxide does not appear to cause neonatal sedation or a difference in Apgar scores. B. The client should inhale nitrous oxide through a face mask as the contraction begins and use it during the contraction. D. Nitrous oxide induces a feeling of relaxation and decreases the client's perception of pain. It does not cause feelings of disorientation
A nurse is caring for a client in labor. Which of the following assessment findings should the nurse report to the provider? FHR baseline of 90 bpm Maternal temp of 37.8 (100F) Uterine relaxation for 1 min between contractions Uterine contractions increasing in intensity
FHR baseline of 90 considered bradycardia associated with fetal cardiac defects, maternal hypoglycemia, fetal viral infection
A nurse is caring for a client experiency prolonged labor. Which of the following fetal monitoring results indicates fetal compromise? Baseline FHR 110-130 Moderate baseline variability Accelerations in response to fetal stimulation Late decelerations with fetal bradycardia
Late decelerations with fetal bradycardia indicates fetus is not tolerating labor and might be compromised. Should be assessed in relation to progression of labor
