CH 5, 11, 12 MATERNITY

A prenatal nurse is providing instructions to a group of pregnant client regarding measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further instructions? A."I need to cook meat thoroughly." B. "I need to avoid touching mucous membranes of the mouth or eyes while handling raw meat." C. "I need to drink unpasteurized milk only." D. "I need to avoid contact with materials that are possibly contaminated with cat feces."

"I need to drink unpasteurized milk only." Rationale: All pregnant women should be advised to do the following to prevent the development of toxoplasmosis. Women should be instructed to cook meats thoroughly, avoid touching mucous membranes and eyes while handling raw meat; thoroughly wash all kitchen surfaces that come into contact with uncooked meat, wash the hands thoroughly after handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption, and avoid contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sandboxes, and garden soil.

The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions? A. "I will not experience mood swings since I was only at 10 weeks of gestation." B. "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months." C. "I should eat foods that are high in iron and protein to help my body heal." D. "I should expect the bleeding to be heavy and bright red for at least 1 week."

"I should eat foods that are high in iron and protein to help my body heal." Rationale: After a miscarriage a woman may experience mood swings and depression from the reduction of hormones and the grieving process. Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months. A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss. The woman should not experience bright red, heavy, profuse bleeding; this should be reported to the health care provider.

During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal heart rate is normal if which of the following is noted? A. 80 BPM B. 100 BPM C. 150 BPM D. 180 BPM

150 BPM Rationale: The fetal heart rate depends in gestational age and ranges from 160-170 BPM in the first trimester but slows with fetal growth to 120-160 BPM near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 BPM with the uterus at rest, the fetus may be in distress.

During pregnancy, alcohol withdrawal may be treated using: A. Disulfiram (Antabuse). B. Corticosteroids. C. Benzodiazepines. D. aminophylline.

Benzodiazepines Rationale: Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids are not used to treat alcohol withdrawal. Symptoms that occur during alcohol withdrawal can be managed with short-acting barbiturates or benzodiazepines.

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: A. A sleepy, sedated affect. B. A respiratory rate of 10 breaths/min. C. Deep tendon reflexes of 2+. D. Absent ankle clonus.

A respiratory rate of 10 breaths/min. Rationale: Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding.

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? A. Administration of blood B. Preparation of the woman for invasive hemodynamic monitoring C. Restriction of intravascular fluids D. Administration of steroids

Administration of blood Rationale: rimary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because this can contribute to more areas of bleeding. Management of DIC includes volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

Thalassemia is a relatively common anemia in which: A. an insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs). B. RBCs have a normal life span but are sickled in shape. C. folate deficiency occurs. D. there are inadequate levels of vitamin B12.

An insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs) Rationale: Thalassemia is a hereditary disorder that involves the abnormal synthesis of the á or â chains of hemoglobin. An insufficient amount of hemoglobin is produced to fill the RBCs.

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: A. Any bleeding, such as in the gums, petechiae, and purpura. B. Enlargement of the breasts C. Periods of fetal movement followed by quiet periods D. Complaints of feeling hot when the room is cool

Any bleeding, such as in the gums, petechiae, and purpura. Rationale: Severe Preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A. Ask the client to turn on her side B. Ask the client to lie flat on her back with the knees and legs flat and straight. C. Ask the mother to urinate and empty her bladder D. Massage the fundus gently before determining the level of the fundus.

Ask the mother to urinate and empty her bladder Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

The emergency department nurse is assessing a pregnant trauma victim who just arrived at the hospital. What are the nurse's MOST appropriate actions? (Select all that apply.) A. Place the patient in a supine position. B. Assess for point of maximal impulse at fourth intercostal space. C. Collect urine for urinalysis and culture. D. Frequent vital sign monitoring. E. Assist with ambulation to decrease risk of thrombosis.

Assess for point of maximal impulse at fourth intercostal space. Collect urine for urinalysis and culture. Frequent vital sign monitoring. Rationale: Passive regurgitation may occur if patient is supine, leading to high risk for aspiration. Placental perfusion is decreased when the patient is in a supine position as well. The heart is displaced upward and to the left in pregnant patients. During pregnancy, there is dilation of the ureters and urethra, and the bladder is displaced forward placing the pregnant trauma patient at higher risk for urinary stasis, infection, and bladder trauma. The trauma patient can suffer blood loss and other complications, necessitating frequent monitoring of vital signs. While the pregnant patient is at risk for thrombus formation, the patient must be cleared by the health care provider before ambulating. The pregnant trauma patient is at higher risk for pelvic fracture, and therefore this condition must be ruled out first as well.

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: A. Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she last ate D. Ascertaining whether the membranes were ruptured

Auscultating the fetal heart Rationale: Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.

From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks: A. in the first trimester. B. between 24 to 36 weeks of gestation. C. during the last 4 weeks of pregnancy. D. immediately postpartum.

Between 24 to 36 weeks of gestation Rationale: The severity of symptoms peaks between 24 and 36 weeks of gestation. Asthma appears to be associated with intrauterine growth restriction and preterm birth. During the last 4 weeks of pregnancy symptoms often subside. The period between 24 and 36 weeks of pregnancy is associated with the greatest severity of symptoms. Issues have often resolved by the time the woman delivers.

During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of: A. euglycemia. B. rheumatic fever. C. pneumonia. D. cardiac decompensation.

Cardiac Decompensation Rationale: Euglycemia is a condition of normal glucose levels. Rheumatic fever can cause heart problems, but it does not present with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms. Symptoms of cardiac decompensation may appear abruptly or gradually.

A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A. Administer magnesium sulfate intravenously B. Assess the blood pressure and fetal heart rate C. Clean and maintain an open airway D. Administer oxygen by face mask

Clean and maintain an open airway Rationale: The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.

The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: A. Clear and dark amber in color B. Milky, greenish yellow, containing shreds of mucus C. Clear, almost colorless, and containing little white specks D. Cloudy, greenish-yellow, and containing little white specks

Clear, almost colorless, and containing little white specks Rationale: By 36 weeks gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A. Placing the client on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Placing a code cart at the client's bedside

Continuous electronic fetal monitoring Rationale: Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply.) A. Decreased urinary output and irritability B. Transient headache and +1 proteinuria C. Ankle clonus and epigastric pain D. Platelet count of less than 100,000/mm3 and visual problems E. Seizure activity and hypotension

Decreased urinary output and irritability Ankle clonus and epigastric pain Rationale: Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: A. mother's age. B. number of years since diabetes was diagnosed. C. amount of insulin required prenatally. D. degree of glycemic control during pregnancy.

Degree of glycemic control during pregnancy Rationale: Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.

Clients with gestational diabetes are usually managed by which of the following therapies? A. Diet B. NPH insulin (long-acting) C. Oral hypoglycemic drugs D. Oral hypoglycemic drugs and insulin

Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic agents are contraindicated in pregnancy. NPH isn't usually needed for blood glucose control for GDM.

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: A. oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. B. dietary modifications and insulin are both required for adequate treatment. C. glucose levels are monitored by testing urine 4r times a day and at bedtime. D. dietary management involves distributing nutrient requirements over three meals and two or three snacks.

Dietary management involves distributing nutrient requirements over three meals and two or three snacks. Rationale: Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis.

A pregnant woman presents to the emergency department complaining of persistent nausea and vomiting. She is diagnosed with hyperemesis gravidarum. The nurse should include which information when teaching about diet for hyperemesis? (Select all that apply.) A. Eat three larger meals a day. B. Eat a high-protein snack at bedtime. C. Ice cream may stay down better than other foods. D. Avoid ginger tea or sweet drinks. E. Eat what sounds good to you even if your meals are not well-balanced.

Eat a high-protein snack at bedtime. Ice cream may stay down better than other foods. Eat what sounds good to you even if your meals are not well-balanced. Rationale: The diet for hyperemesis includes: • Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate liquids from solids and alternate every 2 to 3 hours. • Eat a high-protein snack at bedtime. • Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature. • In general eat what sounds good to you rather than trying to balance your meals. • Follow the salty and sweet approach; even so-called junk foods are okay. • Eat protein after sweets. • Dairy products may stay down more easily than other foods. • If you vomit even when your stomach is empty, try sucking on a Popsicle. • Try ginger tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste. • Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon. • Drink liquids from a cup with a lid.

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: A. One peripad per day B. Two peripads per day C. Three peripads per day D. Eight peripads per day

Eight peripads per day Rationale: The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: A. Every 30 minutes during the first hour and then every hour for the next two hours. B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. C. Every hour for the first 2 hours and then every 4 hours D. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as: A. G = 3, T = 2, P = 0, A = 0, L=1 B. G = 2, T = 0, P = 1, A = 0, L=1 C. G = 1, T = 1. P = 1, A = 0, L= 1 D. G = 2, T = 0, P = 0, A = 0, L=1

G = 2, T = 0, P = 1, A = 0, L=1 Rationale: Pregnancy outcomes can be described with the acronym GTPAL. "G" is Gravidity, the number of pregnancies. "T" is term births, the number of born at term (38 to 41 weeks). "P" is preterm births, the number born before 38 weeks gestation. "A" is abortions or miscarriages, included in "G" if before 20 weeks gestation, included in parity if past 20 weeks AOE. "L" is live births, the number of births of living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? A. Disseminated intravascular coagulation B. Chronic hypertension C. Infection D. Hemorrhage

Hemorrhage Rationale: Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for: A. Hemorrhage. B. Infection. C. Urinary retention. D. Thrombophlebitis.

Hemorrhage Rationale: Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time.

Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes? A. Heroin B. Alcohol C. Phencyclidine palmitate (PCP) D. Cocaine

Heroin Rationale: The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor.

A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A. Hydralazine. B. Magnesium sulfate bolus . C. Diazepam. D. Calcium gluconate.

Hydralazine Rational: Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A. Retake the temperature in 15 minutes B. Notify the physician C. Document the findings D. Increase hydration by encouraging oral fluids

Increase hydration by encouraging oral fluids Rationale: The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: A. Less pressure on her cervix B. Increased efficiency of contractions C. Decreased number of contractions D. The need for increased maternal blood pressure monitoring

Increased efficiency of contractions Rationale: Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A. Normal B. Indicates the presence of infection C. Indicates the need for increasing oral fluids D. Indicates the need for increasing ambulation

Indicates the presence of infection Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? A. Obtain hemoglobin and hematocrit levels B. Instruct the mother to request help when getting out of bed C. Elevate the mother's legs D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided.

Instruct the mother to request help when getting out of bed Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physician's order.

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: A. Bleeding. B. Intense abdominal pain. C. Uterine activity. D. Cramping.

Intense abdominal pain Rationale: Bleeding may be present in varying degrees for both placental conditions. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Uterine activity may be present with both placental conditions. Cramping is a form of uterine activity that may be present in both placental conditions.

The nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function? A. Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics B. Prepare the woman for delivery by cesarean section since this is the recommended delivery method to sustain hemodynamics C. Encourage the woman to avoid the use of narcotics or epidural regional analgesia since this alters cardiac function D. Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling

Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics Rationale: The side-lying position with the head and shoulders elevated helps to facilitate hemodynamics during labor. A vaginal delivery is the preferred method of delivery for a woman with cardiac disease as it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. The use of the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

Maternal and neonatal risks associated with gestational diabetes mellitus are: A. maternal premature rupture of membranes and neonatal sepsis. B. maternal hyperemesis and neonatal low birth weight. C. maternal preeclampsia and fetal macrosomia. D. maternal placenta previa and fetal prematurity.

Maternal preeclampsia and fetal macrosomia Rationale: Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia.

Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for: (Select all that apply.) A. Miscarriage. B. Macrosomia. C. Gestational hypertension. D. Placental abruption. E. Stillbirth

Miscarriage Gestational HTN Placental Abruption Stillbirth Rationale: Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm. These outcomes can be improved with early diagnosis and treatment. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism.

A pregnant woman is being examined by the nurse in the outpatient obstetric clinic. The nurse suspects systemic lupus erythematosus (SLE) after revealing which symptoms? (Select all that apply.) A. Muscle aches Correct B. Hyperactivity C. Weight changes Correct D. Fever Correct E. Hypotension

Muscle Aches Weight Changes Fever Rationale: Fatigue, rather than hyperactivity is a common sign of SLE. Hypotension is not a characteristic sign of SLE. Common symptoms, including myalgias, fatigue, weight change, and fevers, occur in nearly all women with SLE at some time during the course of the disease. Although a diagnosis of SLE is suspected based on clinical signs and symptoms, it is confirmed by laboratory testing that demonstrates the presence of circulating autoantibodies. As is the case with other autoimmune diseases, SLE is characterized by a series of exacerbations (flares) and remissions (Chin and Branch, 2012).

When performing a PP 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 of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in 2 hours D. Encourage increased intake of fluids.

Notify the physician Rationale: Normally, one may find a few small clots 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 most appropriate action is to notify the physician.

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A. Place the client in Trendelenburg's position B. Call the delivery room to notify the staff that the client will be transported immediately C. Gently push the cord into the vagina D. Find the closest telephone and stat page the physician

Place the client in Trendelenburg's position Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: A. Eclamptic seizure. B. Rupture of the uterus. C. Placenta previa. D. Placental abruption.

Placental abruption Rationale: Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? A. Prepare the woman for a dilation and curettage (D&C). B. Place the woman on bed rest for at least 1 week and reevaluate. C. Prepare the woman for an ultrasound and blood work. D. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.

Prepare the woman for an ultrasound and blood work. Rationale: D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.

A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if: A. Blood pressure is reduced to prepregnant baseline. B. seizures do not occur. C. deep tendon reflexes become hypotonic. D. diuresis reduces fluid retention.

Seizures do not occur Rationale: A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration

A pregnant woman in her first trimester with a history of epilepsy is transported to the hospital via ambulance after suffering a seizure in a restaurant. The nurse expects which health care provider orders to be included in the plan of care? (Select all that apply.) A. Valproate (Depakote). B. Serum lab levels of medications. C. Abdominal ultrasounds. D. Prenatal vitamins with vitamin D. E. Carbamazepine (Tegretol).

Serum lab levels of medication Abdominal ultrasounds Prenatal vitamins with Vitamin D Rationale: Carbamazepine (Tegretol) and valproate (Depakote) should be avoided if possible during pregnancy, especially during the first trimester, because their use is associated with NTDs in the fetus. Checking lab levels of medications, performing abdominal ultrasounds to assess fetal growth, and taking prenatal vitamins with vitamin D are all expected interventions for a pregnant woman diagnosed with epilepsy.

A home care nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? A. Blood pressure reading is at the prenatal baseline B. Urinary output has increased C. The client complains of a headache and blurred vision D. Dependent edema has resolved

The client complains of a headache and blurred vision Rationale: If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening Preeclampsia.

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: A. with good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. B. the most important cause of perinatal loss in diabetic pregnancy is congenital malformations. C. infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. D. at birth, the neonate of a diabetic mother is no longer at any greater risk.

The most important cause of perinatal loss in diabetic pregnancy is congenital malformations Rationale: Even with good control, sudden and unexplained stillbirth remains a major concern. Congenital malformations account for 30% to 50% of perinatal deaths. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: A. Until the time it is completely over B. To the end of a second contraction C. To the beginning of the next contraction D. Until the time that the uterus becomes very firm

To the beginning of the next contraction Rationale: This is the way to determine the frequency of the contractions

A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often: A. orthopnea. B. decreasing energy levels. C. moist frequent cough and frothy sputum. D. crackles (rales) at the bases of the lungs on auscultation.

decreasing energy levels Rationale: Orthopnea is a finding that appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Decreasing energy level (fatigue) is an early finding of heart failure. Care must be taken to recognize it as a warning rather than a typical change of the third trimester. Cardiac decompensation is most likely to occur early in the third trimester, during childbirth, and during the first 48 hours following birth. A moist, frequent cough appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Crackles and rales appear later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema.