Lesson 4: Maternity Client: Antepartum Care

A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. The nurse should tell the client: 1. To increase her daily intake of high-fiber foods 2. That this is a normal occurrence during pregnancy 3. To take the iron supplement every other day instead of every day 4. To start taking an oral laxative daily until the constipation resolves

(1) Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.

A nonstress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? 1. Fetal well-being has been established. 2. A contraction stress test will be scheduled. 3. Placental function and oxygenation are adequate. 4. The results are inadequate and the nonstress test must be repeated.

(2) A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if nonstress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.

A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? 1. Week 1 2. Week 5 3. Week 8 4. Week 9

(2) By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore the other options are incorrect.

A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? 1. She must come to the clinic to be checked. 2. This is an expected occurrence during pregnancy. 3. This is frequently the first sign of a breast infection. 4. She should notify the nurse-midwife of this finding.

(2) Colostrum, the creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples as early as 16 weeks' gestation. This is an expected occurrence during pregnancy. It is not necessary for the client to notify the nurse-midwife or to report to the clinic to be checked. It is not a sign of infection.

A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? 1. 4 days 2. 10 days 3. 14 days 4. 21 days

(2) Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.

A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nägele's rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? 1. October 17, 2016 2. November 17, 2016 3. September 17, 2016 4. December 17, 2017

(2) For Nägele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.

Janice Casey, 27 years old, is pregnant for the third time. The nurse completes Janice's obstetric history. Janice tells the nurse that she has one son, born at 40 weeks' gestation, and one daughter, born at 36 weeks' gestation. How does the nurse record Janice's history of gravidity and parity? 1. Gravida 2, para 2 2. Gravida 3, para 2 3. Gravida 3, para 3 4. Gravida 2, para 3

(2) Gravida refers to the number of pregnancies, including the current one. Parity is the number of births (not the number of fetuses - e.g., twins) carried past 20 weeks at delivery, whether or not the fetus was born alive. Because this is the client's third pregnancy, her gravidity is 3. Because Janice is in her first trimester of this pregnancy and also has one son who was born at 40 weeks' gestation and one daughter who was born at 36 weeks' gestation, her parity is 2.

A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? 1. The client is definitely pregnant. 2. The nurse-midwife noted softening of the cervix. 3. The client exhibits a presumptive sign of pregnancy. 4. The nurse-midwife noted a violet coloration of the cervix.

(2) In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.

A nurse prepares to teach a pregnant woman to perform tailor-sitting exercises. Which instruction should the nurse provide to the client? 1. Lie flat on the back and place both feet against a wall. 2. Position self on the hands and knees and arch the back five times in a 30-second period. 3. Sit with the legs straight, press the knees toward the floor, and hold the position for 10 seconds. 4. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes.

(4) Tailor-sitting exercises are useful in alleviating heartburn and shortness of breath or dyspnea. The woman sits on the floor, bends her knees, places the soles together, uses her thigh muscles to press the knees to the floor, and holds the position for 5 to 15 minutes. The other options are incorrect descriptions of this exercise.

A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. 1. Perform the exercise while urinating. 2. Perform the exercise once only after urinating. 3. Repeat the contraction-relaxation cycle 30 times a day. 4. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. 5. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.

(3,4) Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.

Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? 1. The result of the Rh factor screen is normal. 2. Because the Rh factor is not present, no additional testing is necessary. 3. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. 4. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.

(4) If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.

Janice comes to the clinic for her 39-week visit. (Refer to Janice's record by clicking "Chart" below.) Based on the data recorded (refer to medical record), the nurse concludes that one condition may be a problem. What is it? ============================= Blood pressure 162/110 mm Hg Temperature: 98.4° F Pulse 92 beats/min Respirations 14 breaths/min ============================ "I've had a headache for the last few days." "My vision seems blurry lately." "I've had to take off my rings because my fingers are swollen." 1. Eclampsia 2. Mild preeclampsia 3. Severe preeclampsia 4. Chronic hypertension

(3) A client experiencing severe preeclampsia will have a blood pressure of 160/110 mm Hg or higher on two separate occasions and will have 2+ to 3+ proteinuria on dipstick testing. Headaches, blurred vision, and facial and finger edema may also be present. Chronic hypertension would have been detected before pregnancy or before 20 weeks of gestation. Mild preeclampsia presents with a blood pressure of 140/90 mm Hg, minimal or no headache, no vision problems, and proteinuria of less than 2+ on dipstick testing. Eclampsia is an emergency that is characterized by seizure activity and sometimes coma.

A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? 1. The procedure will take about 2 hours. 2. The obstetrician will locate the fetus with the use of the Leopold maneuvers. 3. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. 4. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.

(3) Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.

The nurse, obtaining an obstetric history from Janice, notes that her menstrual periods are regular and that her last period was on August 25, 2016. Janice asks the nurse about her expected date of delivery. Using Nägele's rule, the nurse calculates the estimated date of delivery (EDD) as: 1. May 25, 2017 2. May 31, 2017 3. June 1, 2017 4. July 1, 2017

(3) For Nägele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse subtracts 3 months from the first day of the last menstrual period, adds 7 days, and then adjusts the year as necessary. Subtracting 3 months from August 25, 2016, yields May 25, 2016. Adding 7 days yields June 1, 2016. Adding 1 year to June 1, 2016 brings the EDD to June 1, 2017.

At 30 weeks' gestation, Janice is seen in the maternity clinic for a follow-up visit. The nurse checks the fundal height. Which measurement does the nurse expect to see? 1. 20 cm 2. 26 cm 3. 30 cm 4. 34 cm

(3) From 22 weeks to term, the fundal height, which is measured in centimeters, is roughly equal (±2 cm) to the gestational age of the fetus in weeks. Therefore, because this client is at 30 weeks' gestation, her fundal height would be 30 (±2 cm). If fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause of the unexpectedly large uterine size. If fundal height is less than expected on the basis of gestational age, the estimated date of delivery must be confirmed. If the dates are accurate, further assessment may be necessary to determine whether the fetus' growth is inadequate.

A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? 1. Gravida 2, para 4 2. Gravida 3, para 5 3. Gravida 4, para 2 4. Gravida 5, para 3

(3) Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.

A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? 1. She should cover the discoloration with makeup. 2. She should come to the clinic immediately to be checked. 3. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. 4. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen

(3) Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.

A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? 1. The umbilical cord holds two veins and one artery. 2. Fetal blood circulation takes place strictly in the placenta. 3. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. 4. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.

(3) The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.

A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? 1. Checking the woman's blood pressure 2. Calling the obstetrician to the examining room 3. Placing a cool cloth on the woman's forehead 4. Assisting the client into a lateral recumbent position

(4) When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.

During the 30-week follow-up visit, the nurse assesses Janice and asks, "How are you feeling these days?" Which of these statements from Janice would indicate that further assessment is needed? Select all that apply. 1. "I spend so much time going to the bathroom!" 2. "I haven't been sleeping well for several days." 3. "I've noticed that I get out of breath after I vacuum the floors." 4. "Since yesterday I've noticed that the baby isn't moving as much." 5. "I've noticed that my fingers and face have been swollen when I wake up in the morning."

(4,5) During the second and third trimesters of pregnancy, certain signs and symptoms may indicate complications. Any change in the pattern or frequency of fetal movements should be investigated immediately to detect or rule out fetal jeopardy. Swelling of the face or fingers may indicate a hypertensive condition or preeclampsia. Discomforts that are expected during this trimester of pregnancy include insomnia, frequent urination (caused by impingement of the enlarging uterus on the bladder, resulting in reduced bladder capacity), and shortness of breath (resulting from limitation of diaphragm movement by the enlarging uterus).