course point maternity quizzes

The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems?

"Continue to monitor fetal movements daily." Explanation: The nurse will teach the postterm client to monitor fetal movements (kick counts) daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.

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 will experience quickening, and you will actually feel the baby."

A pregnant client is scheduled to undergo chorionic villus sampling (CVS) to rule out any birth defects. Ideally, when should this testing be completed?

10 to 12 weeks' gestation

A woman comes to the clinic for her first prenatal checkup. The woman has a body mass index (BMI) of 22. The nurse would anticipate that this client should gain approximately how much weight during her pregnancy?

25 to 35 lbs (11 to 16 kg) Explanation: A woman with a BMI of 18.5 to 24.9 is of normal weight and should gain 25 to 35 pounds (11 to 16 kg) during the pregnancy. For a woman who is underweight (BMI <18.5), the total weight gain range is 28 to 40 pounds (13 to 18 kg). For a woman who is overweight (BMI = 25-29.9), total weight gain range should be 15 to 25 pounds (7 to 11 kg). For a woman who is obese (BMI = 30 or higher), the total weight gain range should be 11 to 20 pounds (5 to 9 kg).

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?

300 Explanation: A BMI of 23 is considered a healthy weight. For clients at a healthy weight, 300 additional calories are needed to support fetal growth in the second and third trimester of the pregnancy. If the client had been underweight, more calories would have been recommended; if the client had been obese, less calories would have been recommended.

A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Explanation: The timing of administration of opioids in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, opioids are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

A young couple are very excited to discover they are pregnant and ask the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery?

April 27 Explanation: Naegele rule is to subtract 3 months and add 7 days from the first day of the last menstrual period to determine an expected due date, making the client's due date April 27.

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11. Explanation: The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information.

Which change related to the vital signs is expected in pregnant women?

Blood pressure decreases.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra. Explanation: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

Fetal position Explanation: When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.

A 28-year-old client states that she has not had her menstrual period for the past 3 months and suspects she is pregnant. Which should the nurse do next?

Have the client take a pregnancy test. Explanation: Absence of menstruation, along with consistent nausea, fatigue, breast tenderness, and urinary frequency, are the presumptive signs of pregnancy. To determine if the client may be pregnant, a pregnancy test is indicated.

A pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis?

LDH Explanation: HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a variant of the preeclampsia/eclampsia syndrome. The diagnosis is based on laboratory test results, including: low hematocrit, elevated LDH, elevated AST, elevated ALT, elevated BUN, elevated bilirubin level, elevated uric acid and creatinine levels, and low platelet count. White blood cell counts are not used to evaluate for HELLP.

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize?

Move the infant away from the window. Explanation: The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.

A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition?

Place the client in the left lateral position. Explanation: The symptoms experienced by the client indicate supine hypotension syndrome. When the pregnant woman assumes a supine position, the expanding uterus exerts pressure on the inferior vena. The nurse should place the client in the left lateral position to correct this syndrome and optimize cardiac output and uterine perfusion. Elevating the client's legs, placing the client in an orthopneic position, or keeping the head of the bed elevated will not help alleviate the client's condition.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping. Explanation: It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

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?

Pregnant women often experience mood swings and self-centeredness but this is normal. Explanation: During the first trimester of pregnancy, the woman often has mood swings, bouts of irritability and is hypersensitive. The partner needs to know that these are all normal behaviors for a pregnant woman.

A client at 38 weeks' gestation is diagnosed with placental insufficiency. Which prescription from the health care provider will the nurse anticipate?

Prepare the client for an induction of labor.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus. Explanation: The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.

A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?

Prevent maternal seizures Explanation: The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

Support the client's decision and call the provider. Explanation: Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

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?

The intestines are displaced by the growing fetus.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications. Explanation: Administration of pharmacologic agents such as narcotics too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counterpressure to the lower back. Explanation: Counterpressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?

Uteroplacental insufficiency Explanation: Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.

The clinic nurse teaches a client with pregestational type 1 diabetes that maintaining a constant insulin level is very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

an insulin pump. Explanation: Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully the client maintains diet and balances exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.

The nursing instructor is preparing a class presentation covering the various hormones and their functions during pregnancy. The instructor determines the class is successful when the class correctly matches which function with hCG?

continues progesterone production by corpus luteum

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?

decreased alertness Explanation: Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.

A pregnant client comes to the prenatal clinic complaining of urinary frequency and lower back pain on the right, stating that this has never happened before. An exam validates the diagnosis of pyelonephritis. Which factor would contribute to this condition?

decreased peristalsis of urinary tract Explanation: Renal and ureteral dilation (dilatation) occurs due to hormonal changes during pregnancy. This dilation causes the kidney size to increase, especially on the right. Additionally, peristalsis decreases in the urinary tract, leading to urinary stasis and increased risk of infection. The renal pelvis does not dilate due to the hormones. Increased glomerular filtration rate leads to urinary frequency, not pyelonephritis. Intake of caffeinated beverages may cause urinary tract infections, but since the client has never had urinary problems previously, this should not be the cause.

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

diet Explanation: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are usually not given during pregnancy and would not be the first option. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

intensity of contractions, change in blood pressure, frequency of contractions, uterine resting tone Explanation: The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior Explanation: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

perineum Explanation: Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

Which two tests are generally performed on urine at a prenatal visit?

protein and glucose Explanation: Protein is assessed to help detect hypertension of pregnancy; glucose is assessed to help detect gestational diabetes.

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations. Explanation: Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?

yellow sclera Explanation: The nurse should monitor for yellow skin or sclera in a newborn at risk for developing jaundice due to a high bilirubin. A heart rate of 130 bpm is normal for a newborn, as is a respiratory rate of 24 breaths/minute. Abdominal distention is not a consequence of elevated bilirubin.

A client of African descent at 12 weeks' gestation states concern about her fetus having a genetic disorder. Which statement by the nurse is most appropriate?

"Does anyone in your or your partner's families have a genetic disorder?"

A pregnant client in her first trimester is being seen at the women's clinic. What statement by the nurse would be most beneficial to this client to support her acceptance of the pregnancy?

"Having feelings of uncertainty are very common when a woman becomes pregnant. I will be glad to talk to you about any concerns you may have."

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?" Explanation: The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Explanation: Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the health care provider needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul-smelling both indicate a possible infection and the physician needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable." Explanation: Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement?

"I feel pressure in my vagina when I have the contraction." Explanation: True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.

A nurse is providing care to a postpartum woman who is breastfeeding her 1-day old neonate. While observing the interaction, the woman says to the nurse, "I have noticed some tingling in both of my breasts just before my baby starts to feed and then for a bit during the feeding. What is happening?" Which response by the nurse would be appropriate?

"What you are feeling is the normal let-down reflex when milk is released." Explanation: Typically, during the first 2 days after birth, the breasts are soft and nontender. The woman may also report a tingling sensation in both breasts, which is the "let-down reflex" that occurs immediately before or during breastfeeding. This tingling is not a sign of infection or blockage of the milk ducts. Engorgement is a postnatal physiologic painful condition in which distension and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation. Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours.

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely." Explanation: Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilation (dilatation) but not effacement. Therefore, just saying, "no further dilation (dilatation)" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?

100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum Explanation: A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

A woman at 26 weeks' gestation is undergoing screening for diabetes with a 1-hour oral glucose challenge test. On the client's return visit, the nurse anticipates the need to schedule a 3-hour glucose challenge test based on which result of the previous test?

146 mg/dL (8.10 mmol/L) Explanation: For a 1-hour glucose challenge test, a 75-g oral glucose load is given, without regard to the timing or content of the last meal. Blood glucose is measured 1 hour later; a level above 140 mg/dl (7.77 mmol/L)is abnormal. If the result is abnormal, a 3-hour glucose tolerance test

The nurse is caring for a client after experiencing a placental abruption (abruptio placentae). Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours Explanation: The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5 Explanation: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

A pregnant woman with diabetes is having her hemoglobin (glycosylated) level evaluated. The nurse determines that the woman's glucose is under control and continues the woman's plan of care based on which result?

6.5% Explanation: A hemoglobin (glycosylated) level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. A glycosylated hemoglobin level less than 7% indicates that the plan is working and should be continued.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. Explanation: To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?

Assess for labor progression. Explanation: Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. However, the best first step is to assess the client for labor progress before assisting her otherwise. Bearing down can be a sign that the client is 10 cm dilated

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema. Explanation: Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema. Explanation: This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?

Assess the client's vital signs. Explanation: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Explanation: In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler position owing to the risk of supine hypotension in the supine position and in Trendelenburg position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature?

Assure the newborn has a cap on the head and is kept covered. Explanation: Newborns have a large surface area to body mass ratio and are particularly susceptible to heat loss. The nurse will assure the newborn wears a cap on the head and is kept covered to avoid heat loss. The nurse would monitor intake and output but not related to temperature regulation. The skin of the newborn should be dried well after any liquid is noted (urine, cleansing wipes, etc.) to prevent temperature loss but not specifically because of the large surface area. The newborn's skin needs to be monitored but not specifically for temperature regulation.

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Explanation: Postpartum women who void in small amounts may be experiencing bladder overflow from retention.

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation (dilatation) and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is:

At risk for postpartum depression due to inadequate rest. Explanation: This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.

At which point along the birth canal must the fetal head extend for successful passage?

At the level of the symphysis pubis Explanation: Fetal extension occurs late in the labor process as the fetus extends through the final portion of the passageway. The fetal head must extend at the symphysis pubis for successful passage. The next step is the head being born. The pelvic inlet, iliac crest and ischial spines are high in the birth canal.

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta. Explanation: The nurse is most correct to record the time of the third stage of labor as beginning with the delivery of the fetus and ending with the delivery of the placenta. This time period is generally 5-20 minutes from delivery of the fetus.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum Explanation: Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.

During the physical examination at the first prenatal visit a speculum examination is performed and a bluish-colored cervix is noted. How will the nurse interpret this finding?

Chadwick sign Explanation: Because of increased pelvic congestion during pregnancy, the cervix and vaginal mucosa will have a bluish coloration, which is called Chadwick sign. A softened cervix is called Goodell sign, and the uterine isthmus being softened is called Hegar sign. Naegele rule is used to calculate the expected date of delivery (EDD).

A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priorityconcern in this situation?

Decreased fetal oxygenation Explanation: When there is a cord prolapse the cord becomes compressed, blood flow is interrupted, and there is decreased oxygen available to the fetus resulting in fetal distress. There is a slight increased risk for postbirth infection, but it is not the priority at this time. A cord prolapse does not increase the risk for placental abruption nor does it decrease the strength of uterine contractions.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

Encourage her through the contractions, explaining why she cannot receive any pain medication. Explanation: At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?

Excessive fluid in the infant's lungs, making respiratory adaptation more challenging. Explanation: During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths.

The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first?

Feel for the fetal buttocks or head while palpating the abdomen. Explanation: The first maneuver involves feeling for the buttocks and head at the uterine fundus. Next, the nurse palpates on the side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

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 pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records?

G3 T0 P1 A1 L2 Explanation: G indicates the total number of pregnancies (2 prior, now pregnant = 3); T indicates term deliveries at or beyond 38 weeks' gestation (none = 0); P is for preterm deliveries (at 20 to 37 weeks = 1; multiple fetus delivery are scored as 1); A is for abortions or pregnancies ending before 20 weeks' gestation (1); and L refers to living children which is 2. Thus, G3 T0 P1 A1 L2 is what the nurse should note in the client's record.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. Explanation: The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage Explanation: During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?

Hold the baby frequently. Explanation: The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

Infection Explanation: Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

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. Explanation: When a pregnant woman lies on her back she can experience vena cava syndrome. This results when the weight of the pregnant uterus presses against the vena cava. Additional symptoms of this include weakens nausea and dizziness. To manage this condition, pregnant women are encouraged to assume side lying positions instead of lying on their backs. There is no indication that the client is experiencing cardiac, preeclamptic or diabetes-related manifestations.

The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths. Explanation: The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Explanation: Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.

A pregnant client at 33 weeks' gestation is in the office for a routine visit. She lies down on her back and while the nurse is listening for fetal heart tones, the client tells the nurse that she feels lightheaded; her blood pressure is 82/58 mm Hg. What is the most likely explanation for this problem?

She is experiencing supine hypotension syndrome Explanation: As the uterus gets larger toward the end of the pregnancy, it presses the aorta and vena cava against the spine, causing decreased blood return to the heart. This reduces cardiac output and the woman may feel lightheaded and dizzy and her blood pressure will drop.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Explanation: Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate. Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions. Explanation: The nurse identifies a priority during the active and transitional stage of labor as working with the contractions to give birth. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level is under 7 in the active and transitional phases. Walking in the hall and tolerating liquids also depends on the client.

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus. Explanation: The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life. Explanation: The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 7 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

The tint is due to jaundice. Explanation: Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Jaundice in the first 24 hours is pathologic and must be reported immediately to the health care provider. Jaundice after 2 days is considered physiologic and is due to the liver's inability to adequately process bilirubin which seeps into the tissues, giving the skin a yellowish color. It is not considered normal and does require assessment and intervention. Phototherapy is the recommended treatment of choice, not putting the child in sunlight. It is not a reaction to the vitamin K injection.

Positive signs of pregnancy are diagnostic, meaning nothing else can elicit that sign except pregnancy. What is the earliest positive sign of pregnancy?

Visualization of the gestational sac or fetus Explanation: The positive sign that can be elicited earliest in the pregnancy is visualization of the gestational sac or fetus. With transvaginal ultrasound, the gestational sac can be seen as early as 10 days after implantation.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues?

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding Explanation: During the postpartum period, many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartum blues. The 38-year-old mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.

Which postpartum client will the nurse assess first?

a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated Explanation: A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. If blood pressure is 15 to 20 mm Hg lower after raising the head of the bed upright compared with the supine reading, the woman might be susceptible to dizziness and fainting when she ambulates. Developmentally, 18-year-old teenagers may stay up late and sleep late as a normal sleep cycle. The young 22-year-old packing for discharge is not the priority. A client who had a cesarean birth with minimal blood loss should be allowed to sleep after receiving pain medication and is not the priority.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

a client who had a nonelective cesarean birth Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased. Explanation: Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?

assessing the amount and color of the bleeding Explanation: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure?

brown fat Explanation: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings.

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur?

cervical ripening and softening Explanation: The ripening and softening of the cervix that result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation (dilatation) of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucus plug is expelled as a result of cervical softening and increased pressure of the presenting part.

A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phase based on which assessment findings? Select all that apply.

contractions lasting up to 60 seconds, cervical dilation (dilatation) of 6 cm Explanation: During the active phase, the cervix usually dilates from 4 to 7 cm, with 40% to 80% effacement taking place. Contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). A cervical effacement of 90% and a strong desire to push signify the transition phase.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?

dilation (dilatation) of cervix diameter to 10 cm Explanation: The first stage of labor terminates with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.

Which effect would the nurse identify as a normal physiologic change in the renal system due to pregnancy?

dilation of the renal pelvis

Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management?

episodes of double vision Explanation: Difficulty with vision can occur from cerebral edema or is a symptom of hypertension of pregnancy.

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?

fetal heartbeat

A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?

fetal movement felt by examiner Explanation: The positive signs of pregnancy are fetal image on a sonogram, hearing a fetal heart rate, and examiner feeling fetal movement. A pregnancy test has 95% accuracy; however, it may come back as a false positive. Hegar sign is a softening of the uterine isthmus. Chadwick sign may have other causes besides pregnancy.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree Explanation: The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as:

frequency. Explanation: Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.

A nurse is providing prenatal care to a pregnant woman. Understanding a major component of this care, the nurse would conduct a risk assessment for:

genetic conditions and disorders.

A client who is 37 years of age presents to the health care clinic for her first prenatal checkup. Due to her advanced age, the nurse should prepare to talk with the client about her increased risk for what complication?

genetic disorders

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension Explanation: Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Placental abruption (abruptio placentae), a separation of the placenta from the uterine wall; placenta previa (placenta covering the cervical os); and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?

head elevated, grasping knees, breathing out Explanation: For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma Explanation: If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

A nursing student will pick which value as a correct laboratory value for a newborn?

hemoglobin (Hbg) 17 g/dL (170 g/L) Explanation: The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range.

A nurse is taking a history during a client's first prenatal visit. Which assessment finding would alert the nurse to the need for further assessment?

history of diabetes for 4 years Explanation: A diagnosis of diabetes in a pregnant client increases risk for both the client and the infant during pregnancy and requires close monitoring and follow-up. This client's age, exercise history, and history of occasional OTC pain reliever use do not increase pregnancy risk.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

inability of infant to empty breasts Explanation: For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

inability to concentrate loss of confidence decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate Explanation: Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

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 Explanation: A pregnant client breathes more deeply, which increases the tidal volume of gas moved in and out of the respiratory tract with each breath. The expiratory volume, residual volume, and respiratory rate decrease as the pregnancy progresses. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state.

During a routine antepartal visit, a pregnant woman says, "I've noticed my gums bleeding a bit since I've become pregnant. Is this normal?" The nurse bases the response on the understanding of which effect of pregnancy?

influence of estrogen and blood vessel proliferation Explanation: During pregnancy, the gums become hyperemic, swollen, and friable and tend to bleed easily. This change is influenced by estrogen and increased proliferation of blood vessels and circulation to the mouth. Elevated progesterone levels cause smooth muscle relaxation, which results in delayed gastric emptying and decreased peristalsis. Increased venous pressure contributes to the formation of hemorrhoids. Relaxation of the cardiac sphincter, in conjunction with slowed gastric emptying, leads to reflux due to regurgitation of the stomach contents into the upper esophagus

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby.

The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant. Explanation: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen Explanation: In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse anticipate being used to evaluate the fetus for potential neural tube defects?

maternal serum alpha-fetoprotein analysis Explanation: Alpha-fetoprotein is a substance produced by the fetus. AFP enters the maternal circulation by crossing the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus. The optimal time for AFP screening is 16 to 18 weeks. The triple marker screens for AFP, hCG, and unconjugated estriol. This screens for neural defects and Down syndrome. The Doppler flow study evaluates the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for chromosomal defects.

Many changes occur in the body of a pregnant woman. Some of these are changes in the integumentary system. What is one change in the integumentary system called?

melasma (chloasma) Explanation: The so-called mask of pregnancy, melasma (also known as chloasma) can appear as brown blotchy areas on the forehead, cheeks, and nose of the pregnant woman. This condition may be permanent, or it may regress between pregnancies.

A woman is confused after finding out the ultrasound results predict a different due date for the birth of her baby. Which factor should the nurse point out is most likely the reason for the miscalculation of the fetal age?

mistaking implantation bleeding for last menstrual period (LMP)

The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply.

morning sickness, amenorrhea, breast changes Explanation: Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). Probable signs are signs that appear in the first and early second trimesters, seen via objective criteria, but can also be indicators of other conditions (e.g., hydatidiform mole). Positive signs affirm that proof exists that there is a developing fetus in any trimester and are objective criteria seen by a trained observer or diagnostic study, (e.g., ultrasound.)

A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:

occurring about every 5 minutes. Explanation: The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.

A nursing student is aware that fetal gas exchange takes place in which area?

placenta Explanation: Many different changes occur for the newborn to survive outside the uterus. One such change is that gas exchange that once took place in the placenta now will take place in the lungs.

A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for?

placental abnormalities Explanation: A woman older than 35 years is more likely to conceive a child with chromosomal abnormalities such as Down syndrome. She is also at higher risk for spontaneous abortion (miscarriage), preeclampsia-eclampsia, gestational diabetes, preterm birth, bleeding and placental abnormalities, and other intrapartum complications.

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

postpartum depression. Explanation: Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of:

postpartum depression. Explanation: Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

postpartum diuresis Explanation: The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

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.

postpartum hemorrhage as evidenced by three perineal pads saturated since birth and blood pressure 87/58 mm Hg

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?

relaxin Explanation: As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.

A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?

respiratory rate Explanation: A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?

rupture of membranes Explanation: The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?

showing increased confidence when caring for the newborn Explanation: Showing increased confidence when caring for the newborn is an important aspect of the taking-hold phase. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)?

strong abdominal cramping Explanation: Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.