Ch 52 - NGN PrepU - Maternity, Newborn, and Women's Health Nursing

Probable signs of pregnancy

-Chadwick sign -Hegar sign -abdominal enlargement -Positive pregnancy test

Ovarian cancer

40 years of age moderate to severe bleeding

spontaneous abortions (miscarriage)

40 years of age moderate to severe bleeding painful red bleeding

Uterine fibroids

40 years of age moderate to severe bleeding painful red bleeding longer, heavier menstrual cycles

A nurse is caring for a 33-year-old primigravida client who is obese and near the end of their second trimester. The client has a history of prepregnancy obesity, hypertension, and smoking. The client is at highest risk for developing _________________. The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include _____________.

The client is at highest risk for developing gestational diabetes The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include change in lifestyle

A nurse in a prenatal clinic is caring for a 26-year-old client in the second trimester who has come to the clinic for a scheduled checkup. The nurse performs a focused assessment and discusses unexpected signs and symptoms during the second trimester that, if experienced, will require prompt treatment. The client is at risk for developing ___________, __________, _______________, and _______________, for which the client should report if experienced.

The client is at risk for developing hyperemesis, dysuria, sudden shortness of breath, and diarrhea, for which the client should report if experienced.

A client in their third trimester is being seen in the clinic with new-onset fever, lethargy, and painful urination. Vital signs: temperature, 101.2°F (38.4°C); blood pressure, 110/70 mm Hg; heart rate, 98 beats/min. The nurse recognizes that the client is at risk for developing ______________ as evidenced by _________.

The nurse recognizes that the client is at risk for developing urinary tract infection (UTI) as evidenced by painful urination.

A nurse performs an assessment on a 35-year-old client who developed leg pain. The client smokes one pack of cigarettes per day and drinks alcohol socially. Assessment reveals a red, swollen right lower extremity that is warm to the touch, and pain increases with ambulation or dorsiflexion of the right foot. Client reports recent nausea, vomiting, breast tenderness, and weight gain after starting oral contraceptives. The nurse suspects the client may _______________ as evidenced by ____________________

The nurse suspects the client may have developed a deep vein thrombosis (DVT) as evidenced by calf pain and swelling

placenta previa

bright red blood fundal height greater than expected gestational age decreased hemoglobin increased heart rate decreased blood pressure

placental abruption

pain bright red blood (should be dark) uterine tenderness decreased hemoglobin increased heart rate decreased blood pressure

A community health nurse completes the home visit. The client is 2 weeks postpartum and is breastfeeding. The nurse asks the client if they have any breastfeeding questions. The client statements that require additional teaching are

"Breastfeeding and formula feedings offer the same benefits." I may supplement my breast milk with formula when I am not home I may use a pacifier while breastfeeding when the infant is fussy

Positive signs of pregnancy

-fetal heart sounds -Visualization of fetus by ultrasound

Presumptive signs of pregnancy

-urinary frequency -amenorrhea -nausea and vomiting -breast enlargement

The nurse in the labor and delivery unit is performing a focused assessment on a client who is 2 hours postpartum. Assessment reveals a headache 3 out of 10 on a scale of 0 to 10. Vital signs: temperature, 99.1°F (37.3°C); heart rate, 101 beats/min; blood pressure, 87/58 mm Hg; capillary refill time, less than 3 seconds. Client reports a small gush of blood the first time out of bed to ambulate to the bathroom. Three perineal pads have been saturated since birth. The client is at highest risk for developing _______________ as evidenced by ___________________ and _____________________

The client is at highest risk for developing postpartum hemorrhage as evidenced by three perineal pads saturated since birth and blood pressure 87/58 mm Hg

A nurse in a hospital is caring for a 22-year-old G2P1 client who is at 32 weeks' gestation in active labor. The client calls out, "I think my water broke." The nurse at the bedside pulled back the sheet and found clear fluid with an umbilical cord in the client's vagina. The immediate nursing actions are

The immediate nursing actions are delegate tasks to other nurse, follow the hospital's cord prolapse protocol, insert a hand to hold up the cord, and contact the health care provider.

A nurse is caring for a client who is a 22-year-old gravida 1 para 0 in labor. The client has been in labor for 10 hours. The nurse assesses the fetal monitor, and the client has contractions every 3 to 5 minutes, lasting 40 to 45 seconds, and are palpated moderately. The vaginal examination is completed, and the client is only 3 cm, at 60% effacement, and at -3 station. The client states that the pain level is 7 out of 10 The nurse determines the client is experiencing

The nurse determines the client is experiencing dystocia due to cervical dilation at 3 cm.

A nurse is caring for a 25-year-old G1P0 at 37 weeks' gestation. The client's history indicates that the client has had alcohol abuse disorder throughout their pregnancy. What signs and symptoms does the nurse expect the newborn to exhibit? The nurse recognizes the newborn is exhibiting signs and symptoms of fetal alcohol syndrome, which include ____________, _______________, ____________, and ___________________.

The nurse recognizes the newborn is exhibiting signs and symptoms of fetal alcohol syndrome, which include thin upper lip, high-pitched, shrill cry, jitteriness, and flat midface.

The nurse is performing a focused assessment on a client who is 2 days postpartum. The client reports pelvic pain, chills, profuse dark, foul-smelling lochia with blood clots. The client states, "my bleeding before was light and now it is heavy." Vital signs: temperature, 99.5°F (37.5°C); heart rate, 102 beats/min; blood pressure, 100/66 mm Hg. The nurse suspects the client has _________________ as evidenced by ____________ and ____________________

The nurse suspects the client has retained fragments of placenta urinary tract infection (UTI) as evidenced by pelvic pain and profuse dark lochia with blood clots

A nurse is performing an assessment on a 30-year-old client who is trying to conceive. Past medical history includes: human papillomavirus (HPV) infection and herpes simplex virus. Vital signs: heart rate, 95 beats/min; blood pressure, 100/60 mm Hg. Laboratory values: hemoglobin 14 g/dl (140 g/l); white blood cell count, 6,000/mm3 (6.0 × 109/l). The nurse suspects the client is at highest risk for ______________ as evidenced by _________________

The nurse suspects the client is at highest risk for cervical cancer as evidenced by history of human papilloma virus (HPV)

A nurse is caring for a 28-year-old female client in the emergency department (ED) who is accompanied by their partner. The client reports accidentally falling down stairs. Assessment reveals bruising at multiple stages of healing on upper extremities, back, and abdomen. X-ray reveals a right wrist fracture. The client does not make eye contact with the nurse and allows their partner to answer most of the questions. The nurse suspects the client is experiencing _________________ as evidenced by ____________________.

The nurse suspects the client is experiencing intimate partner violence as evidenced by stages of bruising

A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg. The priority actions of the nurse should be to first _______________________ followed by __________________

The priority actions of the nurse should be to first obtain a culture. followed by initiate antibiotics

A nurse in the hospital nursery cares for a preterm newborn, born at 30 weeks' gestation. The newborn had an APGAR score of 6 at 1 minute (1 point for color, 1 point for respiratory effort, 1 point for muscle tone, 1 point for reflex, 2 points for heart rate) and 8 at 5 minutes. The newborn has a lot of vernix on the whole body, acrocyanosis of the hands, a glucose level of 40 mg/dl (2.22 mmol/l), and a temperature of 96.1°F (35.6°C). To prevent problems for the newborn, the action that the nurse must implement first is________________ followed by ________________ next.

To prevent problems for the newborn, the action that the nurse must implement first is dry newborn to prevent hypothermia followed by observe for respiratory distress next.

A nurse is performing an assessment on a 25-year-old white female client who is obese and is trying to conceive. The client presents to the clinic concerned about a newly found lump in their breast. The nurse explains to the client the difference between benign nodules and breast cancer. The nurse determines client understanding of the difference between a lump that is a benign nodule and a lump that is breast cancer when the client states ________________ is a sign of a benign nodule and _________________ is a sign of breast cancer.

the client states soft and movable is a sign of a benign nodule and hard and fixed is a sign of breast cancer.

A nurse in the hospital is caring for a client at 37 weeks' gestation who experienced premature rupture of the membranes (PROM) more than 24 hours prior to coming to the hospital. The client presents with a fever of 100.4°F (38°C). Due to the client's PROM more than 24 hours prior to arriving to the hospital, the nurse determines the client is at risk for contracting ___________________ and should plan to implement ____________________ o prevent complications.

the nurse determines the client is at risk for contracting group B streptococcus and should plan to implement administer intravenous antibiotics o prevent complications.