Chapter 10, Nursing Care Related to Psychological and Physiologic Changes of Pregnancy

During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as: Hegar sign. Goodell sign. Chadwick sign. Ortolani sign.

Hegar sign

During a prenatal visit at 28 weeks' gestation, the client tells the nurse, "I am always hot now, and usually I am the one wearing an extra sweater. And I normally run a low temperature, around 98.2°F (36.7°C). But when they take it at the clinic, it is between 98.6°F and 98.9°F (37°C and 37.2°C). Do you think I have an infection?" Which responses by the nurse are appropriate in this situation? Select all that apply. Pregnant women typically are 0.4°F to 0.6°F (0.275°C) warmer than their baseline temperatures. The increased metabolic rate during pregnancy makes some women feel warmer. Do you have any signs of an infections, such as painful urination? Let's do an ultrasound and see if the fetus is growing and developing as expected. I will order some blood work to see if you have an infection.

Pregnant women typically are 0.4°F to 0.6°F (0.275°C) warmer than their baseline temperatures. The increased metabolic rate during pregnancy makes some women feel warmer. Do you have any signs of an infections, such as painful urination?

A woman is at 20 weeks' gestation. The nurse would expect to find the fundus at which area? just above the symphysis pubis midway between the pubis and umbilicus at the level of the umbilicus midway between the umbilicus and xiphoid process

at the level of the umbilicus

Which information provided by a client would be considered a presumptive sign of pregnancy? Reports of increased hunger Weight gain Breast tenderness Ballottement

breast tenderness

The nursing instructor is presenting the basic physiologic changes in the woman that can occur during a pregnancy. The instructor determines the session is successful when the students correctly choose which change in the respiratory function during pregnancy as normal? increased tidal volume increased expiratory volume decreased respiratory rate decreased oxygen consumption

increased tidal volume

A client at 24 weeks' gestation is seen for a routine monthly check up. She reports concerns to the nurse about rest periods. She states that when she awakens she feels weak and lightheaded. What is the most appropriate initial action by the nurse? Inquire about the client's sleeping positions. Make a referral for a cardiac evaluation. Request testing to assess the client's serum glucose levels. Assess the client for manifestations of preeclampsia. Complete neurological assessment.

inquire about the clients sleeping positions

The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy? Fatigue Amenorrhea Positive home pregnancy test Nausea and vomiting

positive home pregnancy test

The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time? Dysuria Dyspnea Constipation Urinary frequency

urinary frequency

A nurse assesses a primigravida client and observes darkening of the skin on the client's face. How should the nurse document this pigmentation? Linea nigra Chloasma Spider nevi Palmar erythema

Chloasma

A urinalysis is done on a client in her third trimester. Which result would be considered abnormal? Trace of glucose 2+ Protein in urine Specific gravity of 1.010 Straw-like color

2+ protein in urine

The nurse is counseling a client with a BMI of 23 about weight gain during pregnancy. The nurse teaches the client that during the second and third trimester of pregnancy, dietary intake should be increase by how many calories per day above what she was eating prior to the pregnancy? 100 300 500 1000

300

The nurse obtains a human chorionic gonadotropin (hCG) level from a woman who thinks that she is pregnant. Which result would the nurse identify as a positive pregnancy result? 8 mIU/mL (8 IU/L) 16 mIU/mL (16 IU/L) 24 mIU/mL (24 (IU/L) 32 mIU/mL (32 IU/L)

32 mIU/mL (32 IU/L)

The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective? "I can eat any seafood that I like because it contains phosphorus, which is a nutrient that pregnant women need." "I will need to take iron supplementation throughout my pregnancy even if I am not anemic." "Milk production requires higher levels of calcium; therefore, if I am going to breastfeed, I must take a calcium supplement during pregnancy." "Because I am pregnant, I can eat anything I want and not worry about weight gain."

I will need to take iron supplementation throughout my pregnancy even if I am not anemic

The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are? normal bumps of pregnancy; they do nothing might be sign of cancer; need to speak with health care provider Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples striae, stretching of the breast tissue

Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples

The partner of a pregnant client in her first trimester asks the nurse about the client's behavior recently, stating that she is very moody, seems happy one moment and is crying the next and all she wants to talk about is herself. What response would correctly address these concerns? Her body is changing and she may be angry about it. Pregnant women often experience mood swings and self-centeredness but this is normal. Moodiness and irritability are not usual responses to pregnancy. What you are describing may be normal but we need to talk to her more in depth.

Pregnant women often experience mood swings and self-centeredness but this is normal.

What effect does progesterone have on normal gallbladder function? It has no effect on the gallbladder. The gallbladder will hypertrophy. Progesterone interferes with gallbladder contraction, leading to stasis of bile. Bile will be produced at a more rapid rate due to the progesterone.

Progesterone interferes with gallbladder contraction, leading to stasis of bile.

After teaching a woman about the importance of folic acid in pregnancy, the nurse determines that the teaching was successful when the woman identifies which food(s) as being high in folic acid? Select all that apply. broccoli spinach oranges apples almonds

broccoli spinach oranges

The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting? Slack, soft breast tissue Deeply fissured nipples Enlarged lymph nodes Darkened breast areolae

darkened breast areolae

The client is at 36 weeks' gestation. Which report requires immediate additional assessment by the nurse? "My feet swell up in the late afternoon." "I get leg cramps during the night." "I have been leaking clear, vaginal fluid." "I get heartburn every evening after eating dinner."

i have been leaking clear, vaginal fluid

What would the nurse recommend to a pregnant client at 35 weeks' gestation who reports irregular contractions and lower backache? Have a family member rub her back and place moist heat on it. Lie down and rest and see if the contractions stop and pain subsides. Ask her if she is having urinary frequency that may indicate an infection. Suggest that she try some isometric exercises to relieve the back pain.

lie down and rest and see if the contrats stop and pain subsides

A woman in her third trimester shows the nurse a narrow, brown line that has formed on her abdomen, running from her belly button down to her pubic region. She expresses concern about this and asks the nurse whether it is normal. The nurse explains that this is a normal occurrence of pregnancy and that it results from the release of melanocyte-stimulating hormone from the pituitary, causing the appearance of extra pigmentation on the skin. What is the name of this phenomenon? linea nigra melasma (chloasma) diastasis recti striae gravidarum (stretch marks)

linea nigra

A client who suspects she is pregnant asks the nurse about the accuracy of home pregnancy tests. The nurse would tell the client that: home pregnancy tests often give a false positive result. their reliability is only about 90%. some of the home pregnancy tests can detect the presence of hCG within 1 day of the woman's missed period. The test works best on a midday urine sample.

some of the home pregnancy tests can detect the presence of hCG within 1 day of the woman's missed period.

A pregnant client is visiting the clinic and complains about the tiny, blanched, slightly raised end arterioles on her face, neck, arms, and chest. The nurse should explain that these are normal during pregnancy and referred to as which of the following? Epulis Linea nigra Striae gravidarum Telangiectasias

telangiectasias

The nurse is teaching a pregnant teenager the importance of proper nutrition and adequate weight gain throughout the pregnancy. What is the best response when the client refuses to eat due to fear of possible weight gain? The infant will be small and could have problems. There may be little impact on the infant, but the mother can suffer complications. It will just make the baby smaller, but there are no other problems associated. The infant will be smaller but should quickly gain weight.

the infant will be small and could have problems

Positive signs of pregnancy are diagnostic, meaning nothing else can elicit that sign except pregnancy. What is the earliest positive sign of pregnancy? Finding of hCG in the blood Visualization of the gestational sac or fetus Finding hCG in the urine Positive home pregnancy test

visualization of the gestational sac or fetus

A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client? without a pillow with a pillow under her shoulders with a pillow under her right hip with a pillow under both hips

with a pillow under her right hip

A student nurse is preparing for a presentation that will illustrate the various physiologic changes in the woman's body during pregnancy. Which cardiovascular changes up through the 26th week should the student point out? Decreased pulse rate and increased blood pressure Increased pulse rate and decreased blood pressure Increased pulse rate and blood pressure No change in pulse rate or blood pressure

increased pulse rate and decreased blood pressure

Which change in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy? ligament tightening decreased swayback increased lordosis joint contraction

increased lordosis

The nurse is performing an assessment of a woman who has come to a health care facility for a diagnosis of pregnancy. The women is positive for breast changes, nausea, and amenorrhea. On physical exam, it is noted that the client has softening of the cervix. How should the nurse document this in her notes? ballottement Chadwick sign Goodell sign Hegar sign

goodell sign

A client at 16 weeks' gestation comes to the office for a routine exam. At what location within the abdomen would the nurse anticipate the uterus to be found? At the level of the umbilicus At the xiphoid process Halfway between the symphysis pubis and the umbilicus Below the symphysis pubis

halfway between the symphysis pubis and the umbilicus

A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client? Have you been sexually active in the past 2 months? Do you have a family history of breast cancer? Do you have vaginal itching? Are you taking oral contraceptives?

have you been sexually active in the past 2 months

A pregnant mother may experience constipation and the increased pressure in the veins below the uterus can lead to development of what problem? Varicose veins Umbilical hernia Hemorrhoids Gastrointestinal reflux

hemorrhoids

A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse? "It might be nothing. If it happens again call your provider who is on-call." "If the provider did an exam, it might be just normal vaginal secretions, so don't worry about it." "A one time discharge of bloody mucus in the toilet might have been your mucus plug." "Bloody mucus is a sign you are in labor. Please come to the hospital."

a one time discharge of bloody mucus in the toilet might have been your mucus plug

The nurse has just informed a client that her pregnancy test is positive and she will need further assessment to determine the complete status of the situation. Which initial emotional response does the nurse expect the client to exhibit? ambivalence introversion acceptance emotional lability

ambivalence

A teratogen is _____. Choose the BEST answer. Any chemical or physical factor that can potentially adversely affect the developing fetus A category A, B, or X medication A maternal infection such as toxoplasmosis or rubella A food or medication that may be harmful to the mother or fetus such as alcohol or nicotine

any chemical or physical factor that can potentially adversely affect the developing fetus

Which change related to the vital signs is expected in pregnant women? Pulse decreases. Lung space increases. Blood pressure decreases. Temperature decreases.

blood pressure decreases

During an exam, the nurse notes that the blood pressure of a client at 22 weeks' gestation is lower, and her heart rate is 12 beats per minute higher than at her last visit. How should the nurse interpret these findings? The heart rate increase may indicate that the client is experiencing cardiac overload. The blood pressure should be higher since the cardiac volume is increased. Both findings are normal at this point of the pregnancy. Combined, both of these findings are very concerning and warrant further investigation.

both findings are normal at this point of the pregnancy

A new mother asks the postpartum nurse if her baby is getting enough nourishment from breastfeeding within the first 24 hours following birth. The nurse would provide her what information? The mother needs to supplement breastfeedings with formula until her milk comes in. Breast milk comes in within 12 hours after delivery and nourishment should not be a problem. Most infants need minimal nourishment for the first 24 hours, so the mother should not be concerned. Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well.

colostrum which is the first milk produced is rich in calories and protein that nourishes the infant well

The nurse is caring for a young couple who are expecting their first baby. They are experiencing the phenomenon known as couvade syndrome. What can the nurse explain to this family to help them understand this syndrome? Couvade syndrome is when the pregnant woman becomes self-centered and changes her behavior based on the event taking place inside of her. Couvade syndrome is when the partner begins to experience the same physical symptoms as the pregnant woman experiences. Couvade syndrome is a reflection of an unhealthy relationship between the partner and the pregnancy. The more in tune the partner is with the pregnancy, the less likely this syndrome will take place.

couvade syndrome is when the partner begins to experience the same physical symptoms as the pregnant woman experiences.

Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to: detect fetal heart sounds with a Doppler. feel fetal movements. hear the fetal heartbeat with a stethoscope. palpate the fetal outline.

detect fetal heart sounds with a doppler

Which effect would the nurse identify as a normal physiologic change in the renal system due to pregnancy? decrease in glomerular filtration rate dilation of the renal pelvis reduction in kidney size shortening of the ureters

dilation of the renal pelvis

The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago. The client insists she is not pregnant due to a negative home pregnancy test. Which assessment should the nurse use to assess confirm the pregnancy? Chadwick sign fetal heartbeat positive urine human chorionic gonadotropin (hCG) uterine size and shape changes

fetal heartbeat

A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet? Milk and cheese Carrots, sweet potatoes, and mangoes Nuts, seeds, and chocolate Fortified cereals

fortified cereals

The husband of a pregnant woman in her first trimester tells the nurse that his wife is increasingly preoccupied with herself and her fetus as more signs of the pregnancy present themselves. What should the nurse point out to the husband is probably occurring in this situation? introversion ambivalence acceptance emotional lability

introversion

A woman comes to the clinic reporting her period is late and she is wondering if she is pregnant. Which assessment findings by the nurse would indicate she is exhibiting probable signs of pregnancy? Select all that apply. positive pregnancy test ultrasound visualization of the fetus auscultation of a fetal heart beat ballottement absence of menstruation softening of the cervix

positive pregnancy test ballottement softening of the cervix

A client's menstrual period is two weeks late. She has been feeling tired and has had bouts of nausea in the morning. What classification of pregnancy symptoms is this client experiencing? Positive Presumptive Probable No classification

presumptive

A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation (dilatation) and enlargement of the birth canal. What is this hormone? relaxin progesterone estrogen human placental lactogen

relaxin

A pregnant client at 24 weeks' gestation calls the clinic crying after a prenatal visit, where she had a pelvic exam. She states that she noticed blood on the tissue when she wiped after voiding. What initial statement by the nurse would explain this finding? The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. She may have a bleeding disorder so she needs to come back to the clinic for blood work. It is possible she is losing her mucus plug, which can cause bloody show. Some bleeding during pregnancy is not uncommon and this finding is expected.

the cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual

The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse? There is not enough fiber in your diet. The intestines are displaced by the growing fetus. This shouldn't be happening. hCG is delaying peristalsis.

the intestines are displaced by the growing fetus

A client in her second trimester of pregnancy arrives at the health care facility for a routine follow-up visit. The nurse is required to educate the client so that the client knows what to expect during her second trimester. Which information should the nurse offer? "You may feel physical discomfort as the baby inside grows." "You will experience quickening, and you will actually feel the baby." "You will be more conscious of the changes taking place in your body now." "You may have mood swings that could overwhelm your partner."

you will experience quickening and you will actually feel the baby