Chapter 11 PrepU
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? A. Nausea and vomiting B. Positive home pregnancy test C. Fatigue D. Amenorrhea
B. Positive home pregnancy test A urine pregnancy test is considered a probable sign of pregnancy as the hCG may be from another source other than pregnancy. Fatigue, amenorrhea, and vomiting are presumptive or possible signs of pregnancy and can also have other causes.
The nurse is caring for a client at 8 weeks' gestation who states, "I did not plan for this right now and I am not happy or excited about this pregnancy. I am not sure what to do." Which response by the nurse is best? A. "Many women feel this way during the first trimester." B. "You will become excited and happy when you feel the baby move." C. "We can refer you to a clinic for potential termination if you desire." D. "Do not worry. Once you hold this baby, everything will be fine."
A. "Many women feel this way during the first trimester." The best response is to let the client know this is a common feeling among all pregnant women. Most women experience ambivalence during the first trimester whether the pregnancy was planned or not. Acceptance of the pregnancy commonly occurs during the second trimester when quickening, or feeling the baby move, occurs. However, it is not appropriate for the nurse to assume the client will become excited as each pregnancy is unique and a time of dramatic alterations. Stating not to worry and everything will be fine is nontherapeutic communication and does not focus on the client's concern. The nurse would discuss the client's feelings and concerns before making a referral.
A 17-year-old client arrives for an annual examination and reports no changes since the last exam; however, the nurse assesses a positive Chadwick sign, slightly enlarged uterus, and subsequent positive urine pregnancy test. Which task should the nurse prioritize to assist this client who is denying any possibility that she is pregnant? A. Accepting the pregnancy B. Telling her partner and family C. Accepting the baby D. Preparing for parenthood
A. Accepting the pregnancy Acceptance of pregnancy is multi-factorial, and how the woman responds to the pregnancy is certainly influenced by her age and if the pregnancy was planned. As a teenager, she may not have been trying to get pregnant and may not want to accept the role and experience. Baby and parenthood decisions should all occur later.
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? A. Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well. B. Breast milk comes in within 12 hours after delivery and nourishment should not be a problem. C. The mother needs to supplement breastfeedings with formula until her milk comes in. D. Most infants need minimal nourishment for the first 24 hours, so the mother should not be concerned.
A. Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well. Colostrum is present prior to delivery and provides the infant with adequate nutrition for the first 3 days of life, at which time the mother's actual milk should come in. Formula is not recommended. Infants need nutrition shortly after birth to keep their blood glucose normal.
The nurse cares for a pregnant client at the first prenatal visit and reviews expected changes that will occur during pregnancy. Which information will the nurse include in the education? A. During pregnancy blood volume can increase by at least 40%. B. Blood pressure decreases in the third trimester. C. Hemoglobin levels rise significantly during pregnancy. D. Pregnancy typically causes a decrease in respiratory rate.
A. During pregnancy blood volume can increase by at least 40%. The pregnant woman can experience a blood volume increase by approximately 40% to 50% above prepregnancy levels by the end of the third trimester. Pregnancy results in an increased RR to provide oxygen to both the mother and fetus. Hgb levels are usually low during pregnancy because of hemodilution of RBCs, which is termed physiologic anemia of pregnancy. BP usually reaches a low point mid-pregnancy and, thereafter, increases to prepregnancy levels by the third trimester.
A pregnant mother may experience constipation and the increased pressure in the veins below the uterus can lead to development of what problem? A. Hemorrhoids B. Varicose veins C. Umbilical hernia D. Gastrointestinal reflux
A. Hemorrhoids The displacement of the intestines and possible slowed motility of the intestines can lead to constipation in the pregnant woman. This, along with elevated venous pressure, can lead to development of hemorrhoids.
A pregnant woman questions the nurse about changes she is noticing in her breasts and is concerned if they are normal. Which reported changes would the nurse recognize as normal breast changes during pregnancy? Select all that apply. A. Secretions from sebaceous glands on the areola B. Nodular tissue upon palpation C. Red rash over the anterior breast tissue D. Appearance of striae E. Darkening of the areola
A. Secretions from sebaceous glands on the areola B. Nodular tissue upon palpation D. Appearance of striae E. Darkening of the areola Changes in breast tissue during pregnancy begin early and continue until delivery. Striae or stretch marks appear, the areola darkens, and the breast tissue may feel nodular from the stimulated glandular production and the Montgomery glands (Montgomery tubercles) produce secretions to lubricate the nipples. A red rash is not a normal finding.
During an examination, a client at 32 weeks' gestation becomes dizzy, lightheaded, and pale while supine. What should the nurse do first? A. Turn the client on her left side. B. Take the client's blood pressure. C. Listen to fetal heart tones. D. Ask the client to breathe deeply.
A. Turn the client on her left side. As the enlarging uterus increases pressure on the IVC, it compromises venous return, which can cause dizziness, light-headedness, and pallor when the client is supine. The nurse can relieve these symptoms by turning the client on her left side, which relieves pressure on the vena cava and restores venous return. Although they are valuable assessments, fetal heart tone and maternal blood pressure measurements do not correct the problem. Because deep breathing has no effect on venous return, it cannot relieve the client's symptoms.
A lactose intolerant client is concerned about getting enough calcium in her diet. Which foods could the nurse suggest she include in her diet to increase her calcium intake? Select all that apply. A. broccoli B. peanuts C. molasses D. almonds E. carrots
A. broccoli B. peanuts C. molasses D. almonds The best source of calcium is milk and dairy products, but for women with lactose intolerance, adaptations are necessary. Additional sources of calcium may be necessary. These may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasses. In addition, encourage the woman to drink lactose-free dairy products or calcium-enriched orange juice or soy milk.
A nurse is caring for a pregnant client who has been diagnosed with lordosis. The nurse offers preventive measures for which consequence of lordosis when caring for this client? A. chronic backache B. diastasis recti C. edema in lower extremities D. melasma (chloasma)
A. chronic backache The nurse should provide preventive measures for chronic backache as a consequence of lordosis when caring for this client. Melasma (chloasma) is characterized by darkened areas on the face, particularly over the nose and cheeks. It is also known as the mark of pregnancy. Chloasma is not caused by lordosis. Diastasis recti occurs as the pregnancy progresses when the rectus muscle stretches to the point that it separates. It is not caused by lordosis. Edema in lower extremities occurs due to an impeded venous return caused by the pressure of the growing fetus on pelvic and femoral areas. It is not caused by lordosis.
The nurse is assessing a pregnant client at 20 weeks' gestation and obtains a hemoglobin level. Which result would be a cause for concern? A. 11.9 g/dl B. 10.6 g/dl C. 12.8 g/dl D. 11.2 g/dl
B. 10.6 g/dl The average hemoglobin level at term is 12.5 g/dl. The hemoglobin level is considered normal until it falls below 11 g/dl.
A client calls to cancel an appointment for the first prenatal visit after reporting a home pregnancy test is negative. Which instruction should the nurse prioritize? A. Wait until after two missed menstrual periods. B. Keep the appointment. C. Use a diluted urine specimen. D. Refrain from eating for 4 hours before testing.
B. Keep the appointment. Although home pregnancy tests are accurate 95% of the time, they may still have false positives or false negatives, and the client needs to seek prenatal care and confirmation from her health care provider. Diluting the urine, waiting to miss a second period, or eating before the test would have no effect. The tests look for hCG, which is not affected.
In preparing for a prenatal class to discuss the hormonal changes during pregnancy, which information would the nurse most likely include? A. Most of the hormonal changes are permanent after the pregnancy is completed. B. OTC antacids can be used to treat acid reflux with the health care provider's knowledge. C. Taking hormonal replacement therapy can improve the discomfort of the changes. D. Using herbs will help ease the discomfort.
B. OTC antacids can be used to treat acid reflux with the health care provider's knowledge. Elevated progesterone levels cause smooth muscle relaxation, which can result in relaxation of the cardiac sphincter and reflux of the stomach contents into the lower esophagus. OTC antacids will usually relieve the symptoms but should be discussed with the health care provider first. The hormonal changes are necessary for the pregnancy to continue, and the woman will return to her usual nonpregnant hormonal levels after the baby is born. Taking hormonal replacement therapy is not recommended. Using herbs should be done only with the knowledge of the health care practitioner due to the side effects and contraindications of some herbs during pregnancy. Some herbs will cause a spontaneous abortion (miscarriage).
A nurse is educating a client about the various psychological feelings experienced by a woman and her partner during pregnancy. Which feeling is experienced by the expectant partner during the second trimester of pregnancy? A. ambivalence along with extremes of emotions B. confusion when dealing with the partner's mood swings C. sympathetic response to the partner's pregnancy D. preparation for the new role as a parent and negotiating their role during labor
B. confusion when dealing with the partner's mood swings During the second trimester of pregnancy, partners go through acceptance of their role of breadwinner, caretaker, and support person. They come to accept the reality of the fetus when movement is felt, and they experience confusion when dealing with the woman's mood swings and introspection. During the first trimester, the expectant partner may experience couvade syndrome—a sympathetic response to the partner's pregnancy—and may also experience ambivalence with extremes of emotions. During the third trimester, the expectant partner prepares for the reality of the new role and negotiates what his or her role will be during the labor and birthing process.
During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called? A. cretinism B. couvade syndrome C. pregnancy syndrome D. pseudo pregnancy
B. couvade syndrome Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partner. This phenomenon is called couvade syndrome.
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks' pregnant. The nurse would expect this woman's heart rate to be approximately: A. 95 beats per minute. B. 100 beats per minute. C. 85 beats per minute. D. 90 beats per minute.
C. 85 beats per minute. During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per minute.
A client is about 16 weeks' pregnant and is concerned because she feels her "abdomen" contracting. She calls the primary care provider's office and speaks to the nurse. What is the nurse's most appropriate response to this client's concern? A. "You need to go to the emergency room right away." B. "You need to come to the office to be examined." C. "You have nothing to be concerned about. I am sure you are not feeling contractions at this point in your pregnancy." D. "What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy."
D. "What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy." Braxton Hicks contractions are the painless, intermittent, "practice" contractions of pregnancy.
Which information provided by a client would be considered a presumptive sign of pregnancy? A. Reports of increased hunger B. Ballottement C. Weight gain D. Breast tenderness
D. Breast tenderness Presumptive signs of pregnancy are things reported by the woman to the health care provider and occur early in pregnancy. Breast tenderness is a common sign reported by women in early pregnancy but is not a definitive sign. Reports of increased hunger and weight gain could be caused by any disorder or could be normal responses to eating cycles. Ballottement occurs late in the pregnancy and is a probable sign.
