Chapter 7: Prenatal Care
A gravida woman in her second trimester has shared that she still enjoys a glass of wine about once a week with dinner. What response by the nurse is most appropriate?
"There is no amount of alcohol consumption in pregnancy that is considered safe for the fetus." Explanation: Alcohol ingestion during the pregnancy is considered unsafe at all points in the pregnancy. Alcohol can impact the fetus during each of trimester of pregnancy. There are no exact amounts of alcohol that can be ingested safely. Alcohol impacts each pregnancy and fetus differently. The best course of action is to share the dangers with the woman.
The nurse is screening for potential exposure to toxoplasmosis. Which question is most appropriate?
"Do you have a cat in the house?" Explanation: Toxoplasmosis is caused by a protozoan that is passed from animals (such as cats) to humans via animal feces. If the woman contracts toxoplasmosis while she is pregnant, it can cause a miscarriage or fetal abnormalities
The nurse is providing care for a pregnant client who has been given the necessary requisitions for laboratory work by the primary care provider. The client notices that the lab tests include testing for HIV and other sexually transmitted infections, and expresses alarm, stating, "I don't understand why the doctor would suspect that I've got these diseases." What is the nurse's most therapeutic statement?
"Every pregnant client is tested for these diseases; it doesn't necessarily suggest that the doctor suspects that you have them." Explanation: The nurse should reassure the client that these lab tests are ordered for all clients, not only those who are at high risk for sexually transmitted infections. Making general statements about the incidence of sexually transmitted infections or the need for thorough care does not address the client's expressed concern
The nurse is assessing a client's risk for sexually transmitted infections. Which statement by the client would be cause for concern?
"I am unsure who the father of the baby is. I will be raising it alone." Explanation: While many individuals have complex social issues, if a client states that she is unsure of the father of the baby, it is understood that she has had recent, multiple sex partners. Sex with multiple partners places the client and fetus at risk for a sexually transmitted infection. Not wanting to keep the baby, needing Rho(D) immune globulin, and having social issues does not place the client at risk for sexually transmitted infections
The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which client statement indicates that the nurse's efforts have been successful?
"It was so nice to not have to wait long in the waiting room." Explanation: Strategies to individualize prenatal care include trying to schedule appointments so there won't be a long wait time, providing privacy for weight and blood pressure assessments, educating on care options and encouraging participating in decisions about care, and providing materials on pregnancy in the waiting room.
A gravid woman who is in her first trimester reports experiencing constipation. Which statement by the client indicates the need for further instruction?
"Taking gentle enemas no more frequently than once a week is acceptable." Explanation: Constipation is a common source of concern for many women in pregnancy. It results from the slowing of intestinal peristalsis and also as a side effect of iron administration. Steps such as increasing fluid intake, increasing dietary fiber, and exercising are beneficial in reducing constipation. Weekly enemas during the pregnancy are not advisable. Enemas can be habit forming and do not correct the causes of the constipation being experienced
At 24 weeks' gestation a client is asked to drink a sweet orange solution and then wait an hour to have blood drawn. The client asks if this is the test to determine if she has diabetes. What is the best response by the nurse?
"This is a screening procedure. If your result is elevated you will be scheduled for a longer test to determine if you have gestational diabetes." Explanation: A glucose tolerance test involves a glucose load and a blood glucose level 1 hour later. It is a screening test used to determine if the client needs a full 3-hour oral glucose tolerance test. A 1-hour glucose tolerance test is not diagnostic of insulin resistance nor gestational diabetes. If the screening test is elevated the client is scheduled for the diagnostic test at approximately 24 to 26 weeks' gestation. If a client is eventually diagnosed with gestational diabetes, the initial treatment is diet therapy, not insulin
A primigravida at her 12-week prenatal visit expresses concern that she hasn't felt her baby move yet. What is the best response from the nurse?
"You usually cannot feel them until approximately 16 to 20 weeks." Explanation: The first fetal movements felt by the pregnant woman are usually felt between 16 and 20 weeks gestation. Thirteen weeks is too early (fetus is too small), and movements cannot be felt even if the woman lies down and concentrates on them, although the woman should start feeling movements within the next few weeks
The nurse assesses a 20-week gestational client at a routine prenatal visit. What will the nurse predict the fundal height to be on this client experiencing an uneventful pregnancy?
20 cm Explanation: Between weeks 18 and 32 the fundal height in centimeters should match the gestational age of the pregnancy. At 20 weeks' the fundal height should be at the umbilicus. A fundal height smaller than expected can indicate that the original dates were miscalculated, oligohydramnios, or that the fetus is smaller than expected. If the fundal height is larger than expected this can indicate multiple gestation, the original dates were miscalculated, polyhydramnios, or a molar pregnancy
The nurse is reviewing client data following a regular monthly appointment at 6 months' gestation. Which fundal height requires no further intervention?
24 cm Explanation: An anticipated fundal height for 24 weeks' gestation (6 months) is 24 cm. Between 18 and 32 weeks' gestation, the fundal height in centimeters should match the gestational age. All of the other measurements would require further intervention
A client comes to the clinic for her usual prenatal check up. The nurse measures the fundal height at 24 cm. What is the estimated length of her gestation?
24 weeks Explanation: Fundal height is an approximation of the number of weeks of gestation. Between 20 to 32 weeks, SFH = gestation in weeks + or - 2 cm
How should the nurse document a pregnant client's gestational status using the GTPAL system after collecting the following data? Currently 18 weeks pregnantClient's fourth pregnancyDelivered one nonviable fetus at 26 weeksExperienced one miscarriageDelivered one viable fetus at 38 weeks' gestation
4, 1, 1, 1, 1 Explanation: GTPAL is a more comprehensive system for classifying pregnancy status. By this system, the gravida classification remains the same, but para is broken down into T: the number of full-term infants born (infants born at 37 weeks or after), P: the number of preterm infants born (infants born before 37 weeks), A: the number of spontaneous miscarriages or therapeutic abortions, and L: the number of living children. The client has been pregnant four times. The client delivered one viable infant at 38 weeks. The client delivered one nonviable fetus at 26 weeks. The client had one miscarriage. The client has one living child.
The nurse is assigned to clients who are having the following procedures: amniocentesis, fetal nonstress test, chorionic villus sampling, percutaneous umbilical blood sampling, and Doppler assessment of fetal heart rate. For which clients will the nurse ensure that signed informed consent has been given and is in the client's record?
Amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling Explanation: While the client ultimately consents to all procedures, some require signed documentation of consent within the client's record. An informed consent is needed for an amniocentesis, chorionic villus sampling and a percutaneous umbilical blood sampling due to the invasive nature of the procedures. Both the fetal nonstress test and the Doppler assessment of the fetal heart rate are non-invasive procedures
Why is the first prenatal visit usually the longest prenatal visit?
Baseline data is collected. Explanation: The first prenatal visit is usually the longest because the baseline data to which all subsequent assessments are compared are obtained at this visit
A client at 10 weeks' gestation is complaining of ptyalism over the past 2 weeks. What intervention would the nurse recommend to this client? Select all that apply. Chew gum. Use saline nasal spray. Wear a panty liner. Eat a large, protein rich meal in the evening. Suck on hard candies.
Chew gum Suck on hard candies. Explanation: Ptyalism or excess salivation may be relieved by chewing gum or sucking on hard candies. Many of the interventions used to relieve nausea and vomiting may also work for ptyalism
A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history?
Conduct an interview in a private room to obtain her health history. Explanation: Health interviewing is always conducted best in a quiet, private setting before examination procedures begin
A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history?
Conduct an interview in a private room to obtain her health history. Explanation: Health interviewing is always conducted best in a quiet, private setting before examination procedures begin.
The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is:
December 30
The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is:
December 30 Explanation: Using Naegele rule, since the first day of the client's last menstrual period is March 23, 7 days are added leading to the 30th. Subtracting 3 months from March is December. Thus, December 30 is the estimated date of delivery
The nurse is preparing a care plan for a primigravida client and her partner who are excited about her pregnancy and ask lots of questions on various subjects. Which nursing diagnosis should the nurse prioritize for this client and her partner in this care plan?
Deficient knowledge Explanation: The most appropriate nursing diagnosis in this case would be "deficient knowledge." This can entail various topics to include nutrition, exercise, testing, and even the sex of the baby. The other choices are also potential nursing diagnoses but would involve other types of activities. The couple is not displaying fear but are seeking information that will help them be successful with their pregnancy
Which information is most important in order to decrease the risk of complications if the client decides to work until her due date?
Frequent rest periods Explanation: It is common to have a client work until she goes into labor as long as she has had a low-risk pregnancy. Frequent rest periods are stressed, if possible, as the client progresses throughout the work day. The other options are good suggestions for any client at the end of pregnancy
A pregnant client at 18 weeks' gestation has arrived for her routine prenatal visit. Which assessment findings should the nurse prepare to document at this time? Select all that apply. Fundal height of approximately 18 cm Quickening Insomnia Braxton Hicks contractions Leg cramps
Fundal height of approximately 18 cm Quickening
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of spontaneous abortion (miscarriage) within the first trimester. The nurse is correct to document the history as:
G = 3, T = 1, P = 0, A = 1, L = 1 Explanation: The GTPAL stands for Gravida -- number of pregnancies, which is 3 (current, 4-year-old, and miscarriage); Term -- only one pregnancy thus far carried to term; Preterm deliveries -- 0; Abortions (either elective or miscarriage) -- 1; Living children -- 1. Do not be distracted by the twins. That is still one pregnancy
A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history?
G3 P0020 Explanation: Gravida (G) is the total number of pregnancies she has had, including the present one. Therefore she is G3 and not G2. Para (P), the outcome of her pregnancies, is further classified by the FPAL system as follows: F = Full term: number of babies born at 37 or more weeks of gestation, which is 0 and not 1 in this case. P = Preterm: number of babies born between 20 and 37 weeks of gestation, which is 0 in this case. A = Abortions: total number of spontaneous and elective abortions, which is 2 in this case. L = Living children, as of today. She has no living children; therefore, it is 0 and not 1
A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history?
G3, T0, P1, A1, L1 Explanation: The woman's obstetric history would be documented as G3, T0, P1, A1, L1. G (gravida) = 3 (past and current pregnancy), T (term pregnancies) = 0, P (number of preterm pregnancies) = 1, A (number of pregnancies ending before 20 weeks viability to include miscarriage) = 1, and L (number of living children) = 1.
The nurse is conducting the first prenatal assessment on a newly pregnant client. She shares with the nurse that she has 3 children, 2 born at full-term and one at 34 weeks' gestation. Her last pregnancy ended in a miscarriage. How should the nurse document this client's obstetrical history?
G5 T2 P1 A1 L3 Explanation: One of the most common methods of recording the obstetric history is to use the acronym GTPAL. "G" stands for gravida, the total number of pregnancies including the current one. "T" stands for term, the number of pregnancies that ended at term (at or beyond 38 weeks' gestation); "P" is for preterm, the number of pregnancies that ended after 20 weeks and before the end of 37 weeks' gestation. "A" represents abortions, the number of pregnancies that ended before 20 weeks' gestation to include miscarriage. "L" is for living, the number of children delivered who are alive at the time of history collection. . For this client, G5 = current pregnancy (1) + children (3) + miscarriage (1); T2 = children born at 38+ weeks (2); P1 = children born between 20 and 37 weeks (1); A1 = abortion (0) + miscarriage (1); L3 = number of living children at time of assessment (3)
The nurse is educating a woman about the importance of folic acid before conception and during pregnancy, to prevent neural tube defects in the fetus. The client plans to take prenatal vitamins and minerals. What food source would the nurse recommend to add to the woman's diet?
Green leafy vegetables Explanation: Green leafy vegetables are a good source of folic acid. In the past, green tea was thought to interfere with the absorption of folic acid; however, studies do not support this. The women would be advised to avoid green and iced tea due to the caffeine content. Yogurt, low-fat milk and oily fish are not known to be high in folic acid
The nurse is caring for a neonate whose mother received no medical care for either of her pregnancies. When assessing the neonate's status, which would indicate a potential A, B, and O incompatibility?
Hemolytic anemia Explanation: Antibody screens are done to recognize women who may be at risk of developing antigen incompatibilities with fetal red blood cells. If the incompatibility develops, and is not addressed quickly, the neonate may develop hemolytic anemia as the mother's antibodies cross the placenta and attack the fetus's red blood cells. Hypothyroidism can affect the fetus's nervous system. Dehydration may lead to electrolyte deficiencies. Abnormal bleeding is less common due to the initiation of Vitamin K
When explaining what will occur during the first prenatal visit physical examination, a pregnant client asks why a Papanicolaou test is being done at this time. What should the nurse respond to the client?
It detects cancer cells of the cervix, vulva, or vagina. Explanation: A Papanicolaou test is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not present. A Papanicolaou test is not used to date a pregnancy, detect uterine cancer, or predict if cervical cancer will occur
Why is a Papanicolaou test done at the first prenatal visit?
It identifies abnormal cervical cells. Explanation: A Pap test is a test for cervical cancer. Should abnormal cells be present, the woman may need to make a decision about her priorities of therapy for cervical disease or continuing the pregnancy
A client's last menstrual period was April 11. Using the Naegele rule, her estimated date of delivery (EDD) would be:
January 18. Explanation: To use the Naegele rule, subtract 3 months and then add 7 days to the first day of the client's LMP (April 11): April minus 3 months is January, plus 7 days is 18. Thus, her estimated date of delivery (EDD) would be January 18 of the next year
The nurse is assessing a client at 14 weeks' gestation at a routine prenatal visit and notes the fundal height is at the umbilicus. The nurse will most likely interpret this finding to indicate which situation?
Multiple fetal pregnancy Explanation: The fundus typically is at the level of the umbilicus at 20 weeks' gestation. Therefore the fundal height is greater than that which is expected, suggesting possible multiple gestation, polyhydramnios, fetal anomalies, or macrosomia. Smaller than expected measurements would suggest intrauterine growth retardation or possibly inadequate amount of amniotic fluid. Urinary retention would displace the uterus
The nurse teaches a pregnant client the manifestations associated with complications while pregnant. Which statement indicates that additional client teaching is needed?
Pain with urination is expected during pregnancy." Explanation: Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional client teaching is needed. The client should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy
When describing perinatal education to a pregnant woman and her partner, the nurse emphasizes which goal as the primary one?
Provide knowledge and skills to actively participate in birth and parenting. Explanation: The primary focus of perinatal education is to provide information and support to clients and their families to foster a more active role in the upcoming birth. It also includes preparation for breastfeeding, infant care, transition to new parenting roles, relationships skills, family health promotion, and sexuality. Some methods of birth education focus on pain-free birth. Information provided in birth education classes helps to minimize anxiety and provide the couple with control over the situation, but elimination of anxiety or total control is unrealistic
The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage?
Stretching and breathing exercises such as yoga Explanation: It is important to exercise during pregnancy. One excellent type of exercise includes yoga, which reduces stress and increases relaxation. Yoga also gently stretches muscles and can increase muscle tone. Contact and high-impact sports are not appropriate for the pregnant mother. Hot areas such as a jacuzzi, hot tub, and sauna are also inappropriate
The client is 32 weeks' pregnant and has been referred for a biophysical profile (BPP) after a nonreassuring nonstress test (NST). Which statement made by the client indicates that the nurse's explanation of the procedure was effective?
The BPP is an ultrasound that measures breathing, body movement, tone, and amniotic fluid volume. Explanation: A biophysical profile uses a combination of factors to determine fetal well-being based upon five fetal biophysical variables. An NST is done to measure FHR acceleration. Then an ultrasound is done to measure breathing, body movements, tone, and amniotic fluid volume. Each variable receives a score from 0 to 2 for a maximum score of 10. A score of 6 or less indicates altered fetal well-being and indicates a need for further assessment. A needle is not involved with the BPP. The BPP does not detect placental problems, and the BPP is not a screening for neural tube defects
A client at 16 weeks' gestation is scheduled for prenatal testing. Which of the following would the nurse anticipate as the most likely screening test for congenital anomalies based on the current age of this pregnancy?
amniocentesis Explanation: Amniocentesis to screen for congenital anomalies can be done starting at 14 weeks' gestation. This procedure carries risks of spontaneous abortion (miscarriage), infection, and placental abruption. Cardiocentesis is used less commonly to determine blood disorders. Chorionic villus sampling is performed at 8 to 12 weeks' gestation. Nuchal translucency testing is done between 11 and 13 weeks' gestation
During pregnancy, the cardinal rule concerning medications and herbal remedies is that all drugs cross the placenta and have a potential impact on the fetus. What is one disease where treatment must continue during pregnancy?
asthma Explanation: Treatment (including medications) for certain diseases and conditions must continue during pregnancy. Examples include epilepsy, asthma, diabetes, and depression
A nurse at the health care facility assesses a client at 20 weeks' gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?
at the level of the umbilicus Explanation: In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 to 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy, the fundus should reach the xiphoid process
Before beginning the initial prenatal examination, a nurse should instruct a client to complete what procedure before undressing?
clean-catch urine Explanation: The first procedure a nurse should ask the client to do is obtain a clean-catch, midstream urine before undressing. Lab tests can be done after the examination is complete. At the first visit, the fetus is too small to be measured or have an ultrasound performed
Which disease process would the nurse screen for under potential genetic disorders?
cystic fibrosis Explanation: Screening of genetically linked disorders is important when obtaining a family history. Cystic fibrosis is a genetically linked disorder. Tuberculosis is an infectious disorder. Rheumatic fever stems from a streptococcus infection. Asthma is a hypersensitivity typically from an environmental allergy
Some pregnant women hire a trained professional to provide support during pregnancy and birth, to provide emotional support during labor and birth, and to aid in establishing breastfeeding. What is the name of the woman who takes this role?
doula Explanation: The pregnant woman may hire a doula to provide support for labor and birth and help with establishing breastfeeding. A doula can also provide support for the postpartum period
How should the nurse record the obstetric history for a newly pregnant client who previously delivered two live infants at term and had one abortion at 12 weeks' gestation?
gravida 4, para 2 Explanation: Gravida is defined as a woman who has been pregnant or is currently pregnant, regardless of gestation. Para is defined as the number of pregnancies that have reached viability, regardless of whether the infants were born alive or the number of infants delivered from that pregnancy. The client was pregnant three times in the past and is currently pregnant (Gravida 4). The client delivered two live births (Para 2). The aborted fetus is not included in the para count
Select the acceleration on the fetal monitoring tracing. (Drag and resize the white box so it covers the area that correctly answers the question.)
highest point on graph
The nurse is advising a pregnant woman during her first prenatal visit regarding the frequency of future visits. Which schedule is recommended for prenatal care?
once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth Explanation: The best health for mother and baby results when the mother has her first visit before the end of the first trimester (before the end of week 13) and then has regular visits until after she has delivered the baby. The usual timing for visits is about once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth
Click to highlight the findings that will require follow-up A nurse is caring for a 20-year-old primigravida client who is at 18 weeks' gestation. The client had been experiencing occasional nausea and vomiting in the morning and now reports persistent nausea and vomiting in the past 48 hours. Client has lost 3 lb (1.36 kg) in 2 days. The nurse performs a comprehensive assessment on the client. Vital signs: heart rate, 110 beats/minblood pressure, 88/56 mm Hg. Laboratory values: blood urea nitrogen (BUN), 25 mg/dl (8.93 mmol/l) and sodium 148 mEq/l (148 mmol/l).
persistent nausea and vomiting in the past 48 hours lost 3 lb (1.36 kg) in 2 days heart rate, 110 beats/min blood pressure, 88/56 mm Hg blood urea nitrogen (BUN), 25 mg/dl (8.93 mmol/l) sodium 148 mEq/l (148 mmol/l) Explanation: Hyperemesis gravidarum usually occurs during the first trimester of pregnancy due to high human chorionic gonadotropin (hCG) levels. Hyperemesis gravidarum is persistent nausea and vomiting with weight loss due to inability to ingest food or fluid, which leads to dehydration. A 3-lb (1.36-kg) weight loss in 2 days due to persistent nausea and vomiting is an indication the client is experiencing hyperemesis gravidarum. The weight loss is due to the client's inability to ingest food or fluids, which leads to severe dehydration and malnutrition. The nurse should request intravenous fluids. A blood urea nitrogen (BUN) level of 25 mg/dl (8.9 mmol/l) (normal: 8 to 20 mg/dl; 2.9 to 7.5 mmol/l) is an indication that the client is dehydrated.A serum sodium level of 148 mEq/l (148 mmol/l) (normal: 135 to 145 mEq/l; 135 to 145 mmol/l) is an indication that the client is dehydrated. A blood pressure of 88/56 mm Hg may be an indication of dehydration. A heart rate of 110 beats/min is a compensatory mechanism due to the low blood pressure. Nausea and vomiting in the morning is common in the first trimester. Hyperemesis gravidarum is persistent nausea and vomiting, with weight loss due to the inability to tolerate food or fluids
The nurse is assessing a woman who is pregnant for the first time. Which of the following terms applies to this client?
primigravida Explanation: Gravida refers to a woman who is or has been pregnant. Primigravida refers to a woman who is pregnant for the first time, which is the case in this scenario. Multigravida refers to a woman who has been pregnant previously. Nulligravida refers to a woman who has never been and is not currently pregnant. Para refers to the number of pregnancies that have reached viability, regardless of whether the infants were born alive. Primipara refers to a woman who has given birth to one child past the age of viability
During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. This occurs about 4 or 5 times during the testing period. The nurse interprets this as:
reactive pattern. Explanation: A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm
Which client immunization titer is most important to assess and document in the prenatal record of the pregnant woman?
rubella Explanation: Rubella (German measles) is an infection caused by the rubella virus. The virus causes a rash and mild symptoms in children but can be teratogenic to a fetus. A rubella titer determines if the mother is immune to the virus. If the mother is not immune, she will receive a rubella immunization immediately after delivery. Diphtheria and polio are infant vaccines but not as teratogenic to the fetus. Rotavirus is a gastrointestinal virus typically mild in adults
The nurse is reviewing all of the documentation on determining estimated date of delivery. Which objective data is included? Select all that apply. sonogram CT Scan fundal height last day of menstrual period calculating Naegele rule Pelvic exam findings
sonogram fundal height calculating Naegele rule Explanation: The following provide objective data on the estimated date of delivery (EDD). The sonogram (a gold standard) provides detailed fetal measurements confirming the gestational age. The fundal height provides growth data, and Naegele rule calculates the estimated date of delivery using the first day of the last menstrual period. A CT scan is not ordered. Pelvic exam findings provide data that the client is pregnant and can also provide data that true labor has begun
While triaging messages from the answering machine from clients with the following symptoms, which client would obtain the first visit of the day?
the client at 11 weeks' gestation experiencing abdominal cramping Explanation: The nurse is correct to have the client with the most acute symptom to have the earliest appointment. The client with the most acute symptom is the client in the first trimester experiencing abdominal cramping. The other clients are experiencing common discomforts of pregnancy
The nurse is assisting a primigravida on calculating the due date of her baby using Naegele rule. The most important information provided by the mother is:
the first day of the last menstrual period. Explanation: Naegele rule is calculated using the first day of the last menstrual period. From there, 7 days are added and then 3 months are subtracted. The ovulation date, intercourse date, or last day of the menstrual period are not needed
The nurse is reinforcing health care provider education on the technique for an amniocentesis. Which piece of equipment will the nurse have ready?
ultrasound equipment Explanation: First, the health care provider identifies a pocket of amniotic fluid using an ultrasound machine. A scalpel is not used in the procedure. A urine culture is not obtained prior to the procedure nor is a Foley catheter inserted
A nurse is assessing a pregnant client. Which of the following would the nurse document as an abnormal finding in a pregnancy?
visual changes Explanation: Visual changes are not seen in a normal pregnancy. They are only seen in the case of pregnancy-induced hypertension. Lordosis, pedal edema, and linea nigra are changes seen in a normal pregnancy
