N144 AQ Pregnancy, labor, childbirth, postpartum

A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments? Report the findings because the client needs immediate intervention. Document the results because they are expected at 20-weeks' gestation. Record the findings in the medical record because they are not within the norm but are not critical. Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.

Document the results because they are expected at 20-weeks' gestation. Rationale All data presented are expected for a client at 20-weeks' gestation and should be documented. There is no need for immediate intervention or an emergency admission because all findings are expected.

The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching? "The fetus keeps growing throughout pregnancy." "The fetus may be underweight if it's exposed to smoke." "The fetus gets nutrients from the amniotic fluid." "The fetus gets oxygen from blood in the placenta."

"The fetus gets nutrients from the amniotic fluid." Rationale The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? Prolong the course of labor Cause decreased placental perfusion Lead to transient episodes of hypertension Interfere with free movement of the coccyx

Cause decreased placental perfusion Rationale In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.

How does the nurse determine when true labor and not false labor is present? Cervical dilation is evident. Contractions stop when the client walks around. The client's contractions progress only when she is in a side-lying position. Contractions occur immediately after the membranes rupture.

Cervical dilation is evident. Rationale Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions will increase with activity. Contractions of true labor persist in any position. Contractions may not begin until 24 to 48 hours after the membranes rupture.

A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part? Entering the vagina Floating within the bony pelvis At the level of the ischial spines Above the level of the ischial spines

At the level of the ischial spines Rationale The ischial spines are used as landmarks in relation to the fetus's head, because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines. When the head enters the vagina it is below the ischial spines and its position is designated with positive numbers (+1 to +4). When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (-1 to -4).

During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent? Fetal hypoxia Perineal lacerations Carpopedal spasms Maternal hypertension

Fetal hypoxia Rationale Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.

A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram? Empty her bladder. Avoid eating for 8 hours. Take a laxative the night before the test. Increase fluid intake for 1 hour before the procedure.

Increase fluid intake for 1 hour before the procedure. Rationale In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation.

A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What should the nurse do first? Give her the bedpan. Change the bed linens. Inspect her perineal area. Take an oral temperature.

Inspect her perineal area. Rationale Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.

What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? Scant alba Scant rubra Moderate rubra Moderate serosa

Moderate rubra Rationale The uterus sloughs off the blood, tissue, and mucus of the endometrium postdelivery. This happens in three stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that's expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for about seven days. Lochia serosa is the second stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts about two weeks although for some women it can last up to four to six weeks postpartum. Lochia alba is the final stage of lochia, rather than blood you'll see a white or yellowish discharge that's generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around six weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than two weeks.

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? Reposition the client from supine to left lateral. Increase the intravenous flow rate from 125 to 150 mL/hr. Administer oxygen at a rate of 8 to 10 L/min by way of face mask. Assess the maternal blood pressure for a systolic pressure below 100 mm Hg.

Reposition the client from supine to left lateral. Rationale Hypotension is a common side effect of epidural anesthesia that results in decreased placental perfusion and late decelerations on the fetal monitor. The priority intervention is repositioning the client to relieve compression of the vena cava and increase venous return, which in turn increases placental perfusion. Administering oxygen and increasing the flow rate are correct interventions, but neither is the priority because these interventions would not be effective until compression of the vena cava has been relieved and placental perfusion increased. Assessing the maternal blood pressure for a systolic pressure below 100 mm Hg only provides data and does not correct the late deceleration.

The electronic fetal monitor displays contractions every 2 minutes and lasting 95 seconds. What is the nurse's highest priority intervention at this time? Stop the oxytocin (Pitocin) infusion. Administer oxygen at 8 to 10 L/min. Increase the main line fluid delivery rate to 150 mL/hr. Prepare the client for insertion of an intrauterine pressure catheter.

Stop the oxytocin (Pitocin) infusion. Rationale The contraction pattern indicates hyperstimulation of the uterus. Stopping the oxytocin infusion permits relaxation of the uterus and perfusion of the placenta. Oxygen cannot reach the placenta until the uterus is relaxed, so administering oxygen will not help. Increasing the rate of delivery of the main line fluid does not affect hyperstimulation of the uterus. Insertion of an intrauterine pressure catheter will only provide measurement of the internal uterine pressure and will not affect uterine contractions.

A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond? "Your lower rib cage is more restricted." "Your diaphragm has been displaced upward." "Your lungs have increased in size since you got pregnant." "The height of your rib cage has increased since you got pregnant."

"Your diaphragm has been displaced upward." Rationale The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration. The lower rib cage expands; it does not become restricted. There is no change in the size of the lungs during pregnancy. The thoracic cage enlarges; it does not rise.

While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats per minute that lasts 15 seconds. How should the nurse document this event? An acceleration An early increase A sonographic motion A tachycardic heart rate

An acceleration Rationale pAn acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats per minute.

A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed? Diminished bloody show Increased and more variable fetal heart rate Less discomfort with contractions Progressive dilation and effacement

Progressive dilation and effacement Rationale Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after the membranes are artificially ruptured.

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse's action be to confirm that the membranes have ruptured? Take the client's oral temperature. Test the leaking fluid with Nitrazine paper. Obtain a clean-catch urine specimen. Inspect the perineum for leaking fluid.

Test the leaking fluid with Nitrazine paper. Rationale Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the initial assessment. Although this may be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic fluid. Inspecting the vagina for leaking fluid will not confirm rupture of the membranes.

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. How should the nurse respond? "These accelerations are a sign of fetal well-being." "These accelerations indicate fetal head compression." "Umbilical cord compression is causing these accelerations." "Uteroplacental insufficiency is causing these accelerations."

"These accelerations are a sign of fetal well-being." Rationale The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.

A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? Increasing the infusion rate Checking for a distended bladder Continuing to perform fundal massage Continuing to assess the blood pressure

Checking for a distended bladder Rationale A displaced and boggy uterus is usually the result of a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus. If still boggy, the uterus should be massaged until firm. The oxytocin infusion may need to be increased if voiding and fundal massage are ineffective; however, the healthcare provider must be notified to change the order. Continuing to perform fundal massage is necessary if the fundus remains boggy after the client has voided. Continuing to assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the priority.

A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take? Discontinuing the test because the pattern is within the normal range Encouraging the client to drink more fluids to decrease the fetal heart rate Notifying the primary healthcare provider and preparing for an emergency birth Recording this nonreassuring pattern and continuing the test for further evaluation

Discontinuing the test because the pattern is within the normal range Rationale The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what? Estimate fetal age Detect hydrocephalus Rule out congenital defects Approximate fetal linear growth

Estimate fetal age Rationale Measurement of the crown-rump length (CRL) is useful in approximating fetal age in the first trimester. Hydrocephalus cannot be detected during the first trimester. Ultrasonography is used to detect structural defects in the second trimester. It is too early in this pregnancy to determine fetal linear growth.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? First Second Prodromal Transitional

First Rationale The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

What common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? Intrusion on movement Inability to take sedatives Interference with breathing techniques Increased frequency of vaginal examinations

Intrusion on movement Rationale Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.

Which statements regarding the involution process are correct? Select all that apply. Involution begins immediately after expulsion of the placenta. Involution is the self-destruction of excess hypertrophied tissue. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a nonpregnant state after birth. Involution may be caused by retained placental fragments and infections.

Involution begins immediately after expulsion of the placenta. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a nonpregnant state after birth.

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action? Notifying the healthcare provider Resuming continuous fetal heart monitoring Continuing to monitor the maternal vital signs Documenting the fetal heart rate as an expected response to contractions

Notifying the healthcare provider Rationale Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.

On a routine prenatal visit, what is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? Quickening Palpitations Pedal edema Vaginal spotting

Quickening Rationale The recognition of fetal movement commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting at this time requires immediate follow-up care.

A client tells the nurse that the first day of her last menstrual period was July 22. What is the estimated date of birth (EDB)? May 7 April 29 April 22 March 6

Rationale Her EDB is April 29. The Nägele rule is an indirect, noninvasive method for estimating the date of birth: EDB = last menstrual period + 1 year - 3 months + 7 days. May 7 is beyond the expected date of birth. April 22 and March 6 are both before the EDB.

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? Kidney defects Cardiac anomalies Neural tube defects Urinary tract anomalies

Rationale The alpha-fetoprotein test can detect not only neural tube defects, but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.

When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? There is a slow rate of involution. There are retained placental fragments. The bladder has become overdistended. The uterine ligaments are overstretched.

The bladder has become overdistended. Rationale A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced, and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.

Which information should the nurse include in the discharge teaching of a postpartum client? The prenatal Kegel tightening exercises should be continued. The episiotomy sutures will be removed at the first postpartum visit. She may not have a bowel movement for up to a week after the birth. She should schedule a postpartum checkup as soon as her menses returns.

The prenatal Kegel tightening exercises should be continued. Rationale Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.

A client in active labor has requested epidural anesthesia for pain management . The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation? It is the policy of the institution to provide 2 bags of lactated Ringer solution. There is a risk of hypotension, and the large amount of IV fluid reduces this risk. Giving the large amount of IV fluid is a means of hydrating the client when she is unable to drink. The client must be given 500 mL of fluid to ascertain that the line is patent.

There is a risk of hypotension, and the large amount of IV fluid reduces this risk. Rationale Once an epidural is initiated there is a risk of hypotension (low blood pressure), which may result in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural medication is administered through a catheter placed by the anesthetist. Quoting institutional policy does not provide the explanation for administering the solution. Providing 500 mL of fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of determining that the line is patent before the administration of medication.

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? Turn her onto her left side Elevate the head of the bed Place her feet on several pillows Give her oxygen via a face mask

Turn her onto her left side Rationale The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase blood pressure. Raising the head of the bed will not relieve uterine compression of the large vessels. Elevating the feet will not relieve uterine compression of the large vessels. Oxygen administration will not relieve uterine compression of the large vessels.