Related questions of Saunders Test PREP off website 8th edition
The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initialaction should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? Allow family members to name the infant. Encourage the client to talk about the dead fetus. Allow the client and the spouse to hold the infant. Assess the client's and the spouse's perception of the event.
Assess the client's and the spouse's perception of the event-The initial intervention in planning to meet the emotional needs of the client and her spouse is to assess their perception of the event. Although the actions in the remaining options are likely to be components of the plan of care, the initial intervention in planning is to assess the perception of the event.
A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? Nalbuphine Betamethasone Rho(D) immune globulin Dinoprostone vaginal insert
Betamethasone Rationale: Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? Uterine tone Blood pressure Amount of lochia Deep tendon reflexes
Blood pressure-Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The obstetrician needs to be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, blood pressure is related specifically to the administration of this medication.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Uterine rigidity Uterine tenderness Severe abdominal pain Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age
Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation, as the blood penetrates the myometrium and causes uterine irritability.
The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? Changes in vital signs Signs of heavy bruising Complaints of intense pain Complaints of a tearing sensation
Changes in vital signs-Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? Document the finding. Encourage the client to ambulate. Encourage the client to increase fluid intake. Contact the obstetrician (OB) and inform him or her of this finding.
Contact the obstetrician (OB) and inform him or her of this finding-Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized.
The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? Paleness of the calf area Coolness of the calf area Enlarged, hardened veins Palpable dorsalis pedis pulses
Coolness of the calf area-Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? Delivery of the fetus Strict monitoring of intake and output Complete bed rest for the remainder of the pregnancy The need for weekly monitoring of coagulation studies until the time of delivery
Delivery of the fetus-Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? Delivery of the fetus Strict monitoring of intake and output Complete bed rest for the remainder of the pregnancy The need for weekly monitoring of coagulation studies until the time of delivery
Delivery of the fetus-Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? Providing sitz baths Encouraging fluid intake Placing ice on the perineum Monitoring hemoglobin and hematocrit levels
Encouraging fluid intake -Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.
The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? Administer oxygen to the woman. Transport the woman to the delivery room. Place an external fetal monitor on the woman. Exert upward pressure against the presenting part.
Exert upward pressure against the presenting part-If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place.
The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply Flushing Hypertension Increased urine output Depressed respirations Extreme muscle weakness Hyperactive deep tendon reflexes
Flushing Depressed respirations Extreme muscle weakness Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? Infection Hemorrhage Chronic hypertension Disseminated intravascular coagulation
Hemorrhage-In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? Age 35 years History of syphilis History of genital herpes History of diabetes mellitus
History of syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion, although the presence of active lesions at the time of birth presents concerns. Maternal age greater than 40 years and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations, not abortions.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? Document the findings. Notify the obstetrician. Retake the temperature in 15 minutes. Increase hydration by encouraging oral fluids.
Increase hydration by encouraging oral fluids-The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the obstetrician is not necessary.
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? Elevate the client's legs. Massage the fundus until it is firm. Ask the client to turn on her left side. Push on the uterus to assist in expressing clots.
Massage the fundus until it is firm-If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? Monitor for fetal movement. Monitor the maternal blood glucose. Instruct the client to maintain complete bed rest. Instruct the client to restrict dietary sodium and any food items that contain sodium.
Monitor for fetal movement-A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary.
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? Record the findings. Massage the fundus. Notify the obstetrician (OB). Place the client in Trendelenburg's position.
Notify the obstetrician (OB)-If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the OB.
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? Document the findings. Notify the obstetrician (OB). Reassess the client in 2 hours. Encourage increased oral intake of fluids.
Notify the obstetrician (OB)-Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the OB. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? Prepare the client for an ultrasound. Obtain equipment for a manual pelvic examination. Prepare to draw a hemoglobin and hematocrit blood sample. Obtain equipment for external electronic fetal heart rate monitoring.
Obtain equipment for a manual pelvic examination-Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.
A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? Prone Supine On the side Reverse Trendelenburg's
On the side-If cord prolapse or compression is suspected, the client is immediately repositioned. Cord compression needs to be relieved to allow for adequate fetal oxygenation. The client may be turned to the side or the hips may be elevated to shift the fetal presenting part toward the diaphragm, thereby relieving cord compression. A hands-and-knees position may reduce compression on a cord that is entrapped behind the fetus. Prone, supine, and reverse Trendelenburg's positions will not shift the presenting part toward the diaphragm and could worsen the condition.
The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply. A tender and rigid uterus Painless, bright red vaginal bleeding Location in the lower uterine segment Greenish discoloration of the amniotic fluid Vaginal bleeding accompanied by abdominal pain
Painless, bright red vaginal bleeding Location in the lower uterine segment Rationale: Placenta previa is a condition in which the placenta is located in the lower uterine segment. It does not cause pain but does cause bright red vaginal bleeding. This occurs because the placenta is overriding the cervical os, and as the cervix dilates the placental vessels bleed. Abruptio placenta is painful and results in a rigid and tender uterus. Greenish discoloration of the amniotic fluid occurs as a result of meconium staining.
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history? Hypotension Hypothyroidism Diabetes mellitus Peripheral vascular disease
Peripheral vascular disease-Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids.
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? Gently push the cord into the vagina. Place the client in Trendelenburg's position. Find the closest telephone and page the primary health care provider stat. Call the delivery room to notify the staff that the client will be transported immediately.
Place the client in Trendelenburg's position-When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation.
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? Encourage ambulation hourly. Assess vital signs every 4 hours. Measure fundal height every 4 hours. Prepare an ice pack for application to the area.
Prepare an ice pack for application to the area-Rationale: A hematoma is a localized collection of blood in the tissues of the reproductive tissues after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. Proteinuria Hypertension Low-grade fever Generalized edema Increased pulse rate Increased respiratory rate
Proteinuria Hypertension Rationale: The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. Proteinuria of 3 + Respirations of 10 breaths per minute Presence of deep tendon reflexes Urine output of 20 mL in an hour Serum magnesium level of 4 mEq/L (2 mmol/L)
Respirations of 10 breaths per minute Urine output of 20 mL in an hour Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3 + is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L).
A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? Urinary output of 20 mL Deep tendon reflexes of 2+ Fetal heart rate of 120 beats/minute Respiratory rate of 10 breaths/minute
Respiratory rate of 10 breaths/minute Rationale: Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the health care provider needs to be notified and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus.
A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? Immunization with rubella Retesting rubella titer during pregnancy Antibiotics to be taken throughout the pregnancy Counseling the mother regarding therapeutic abortion
Retesting rubella titer during pregnancy-A rubella titer is performed to determine immunity to rubella. If the client's titer is less than 1:8, the mother is not immune. A retest during pregnancy is prescribed, and the mother is immunized postpartum if she is not immune. Antibiotics are not prescribed. Counseling the client regarding therapeutic abortion is an inaccurate option.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? Supine position with a wedge under the right hip Trendelenburg's position with the legs in stirrups Prone position with the legs separated and elevated Semi-Fowler's position with a pillow under the knees
Supine position with a wedge under the right hip-Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery.
After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? Encourage the mother to breast-feed soon after birth. Support the mother in her reaction to the newborn infant. Tell the mother that it is important to hold the newborn infant. Document a complete account of the mother's reaction on the birth record.
Support the mother in her reaction to the newborn infant-Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.
The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? The client is 28 years of age. This is the second pregnancy. The client has a history of hypertension. The client performs moderate exercise on a regular daily schedule.
The client has a history of hypertension-Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? The client with mild afterpains The client with a pulse rate of 60 beats per minute The client with colostrum discharge from both breasts The client with lochia that is red and has a foul-smelling odor
The client with lochia that is red and has a foul-smelling odor
The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? "I don't like my figure anymore. My clothes are all too tight." "I don't like my breasts anymore. These silver lines are ugly." "I don't like my stomach anymore. That brown line is disgusting." "I don't like my face anymore. I always look like I have been crying."
"I don't like my face anymore. I always look like I have been crying." Rationale: In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent.
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? "I should breast-feed every 2 to 3 hours." "I should change the breast pads frequently." "I should wash my hands well before breast-feeding." "I should wash my nipples daily with soap and water."
"I should wash my nipples daily with soap and water."-Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? "I will watch to see if I pass any tissue." "I will maintain strict bed rest throughout the remainder of the pregnancy." "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." "I will avoid sexual intercourse until the bleeding has stopped and for 2 weeks following the last episode of bleeding."
"I will maintain strict bed rest throughout the remainder of the pregnancy." Rationale: Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client should watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider.
A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? "I will need to remain on bed rest for 2 weeks." "I will need to take a full course of antibiotic treatment." "I will need to take tocolytic medication to halt the labor process." "I will need to prepare myself and my family for the loss of this pregnancy."
"I will need to prepare myself and my family for the loss of this pregnancy." Rationale: The client is experiencing a spontaneous abortion (miscarriage), which cannot be prevented and will terminate her pregnancy. Bed rest will not reverse this process.
A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? "My vision for the past 2 days has been really fuzzy." "The swelling in my hands and ankles has gone down." "I had heartburn yesterday after I ate some spicy foods." "I had a headache yesterday, but I took some acetaminophen and it went away."
"My vision for the past 2 days has been really fuzzy." Rationale: Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia.
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. "You should avoid all school-age children during pregnancy." "There is no need to be concerned if you don't have a fever or rash within the next 2 days." "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." "Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester."
"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." Rationale: Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information.
A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? "You will be isolated from your newborn infant after delivery." "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."
"You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed." Rationale: With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery.
The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? "Most children do not receive the vaccine until they are 5 years of age." "You are still susceptible to rubella, so your toddler should receive the vaccine." "It is not advised for children of pregnant women to be vaccinated during their mother's pregnancy." "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."
"Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."-All pregnant women should be screened for prior rubella exposure during pregnancy. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to rubella. All children of pregnant women should receive their immunizations according to schedule. In addition, no definitive evidence suggests that the rubella vaccine virus is transmitted from client to client.
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed if the breasts are not too sore. Take the prescribed antibiotics until the soreness subsides. Avoid decompression of the breasts by breast-feeding or breast pump.
*Wear a supportive bra. *Rest during the acute phase. *Maintain a fluid intake of at least 3000 mL/day. *Continue to breast-feed if the breasts are not too sore-Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A primiparous client who delivered 4 hours ago A multiparous client who delivered 6 hours ago A multiparous client who delivered a large baby after oxytocin induction A primiparous client who delivered 6 hours ago and had epidural anesthesia
A multiparous client who delivered a large baby after oxytocin induction-The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage.
A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? A private room across from the elevator A semiprivate room across from the nurses' station A private room 2 doors away from the nurses' station A semiprivate room with another client who enjoys watching television
A private room 2 doors away from the nurses' station Rationale: A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room 2 doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia. The client with severe preeclampsia requires intense nursing observation and care.
The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. Soft uterus Abdominal pain Nontender uterus Firm uterus by palpation Painless vaginal bleeding
Abdominal pain Firm uterus by palpation Rationale: Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized or diffuse over 1 region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? A temperature of 100.4° F (38° C) An increase in the pulse rate from 88 to 102 beats per minute A blood pressure change from 130/88 to 124/80 mm Hg An increase in the respiratory rate from 18 to 22 breaths per minute
An increase in the pulse rate from 88 to 102 beats per minute-During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.
A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 37.2º C (99º F). The nurse plans care based on which interpretation? The woman requires further evaluation for preterm labor. The woman is suffering from an intestinal bacterial infection. The woman is exhibiting signs and symptoms of gestational hypertension. The woman needs instruction on pelvic tilts to decrease her lower back pain.
The woman requires further evaluation for preterm labor. Rationale: Classic signs and symptoms of preterm labor include lower abdominal cramping, possibly accompanied by diarrhea; dull and intermittent low back pain; painful menstrual-like cramps; suprapubic pain or pressure; pelvic pressure or heaviness; urinary frequency; change in character and amount of vaginal discharge; and rupture of amniotic membranes. Early recognition of preterm labor is essential, so interventions such as tocolytic therapy and administration of antenatal glucocorticoids can be initiated; therefore, further evaluation of the cervix, membrane status, uterine activity, and fetal heart rate is necessary to determine if the client is in preterm labor (the correct option). The client's temperature is only slightly elevated, and her diarrhea presents in addition to the signs and symptoms of preterm labor, so option 2 can be eliminated. The client is not exhibiting signs of gestational hypertension, so therefore eliminate option 3. Because the client has additional complaints that may possibly relate to preterm labor, instruction on pelvic tilts to decrease back pain is irrelevant at this time, so therefore eliminate option 4.
The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. Use of diaphragm Use of fertility medications History of Chlamydia Use of an intrauterine device History of pelvic inflammatory disease (PID)
Use of fertility medications History of Chlamydia Use of an intrauterine device History of pelvic inflammatory disease (PID) Rationale: An ectopic pregnancy is one that establishes itself somewhere other than inside the uterus. Multiple factors may predispose a woman to an ectopic pregnancy. Fertility medications, history of sexually transmitted infections, intrauterine devices, and PID have all been associated with ectopic pregnancy. There are no data to support any additional risk for ectopic pregnancy with the use of the diaphragm.
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediatelydiscontinue the oxytocin infusion? Select all that apply. Fatigue Drowsiness Uterine hyperstimulation Late decelerations of the fetal heart rate Early decelerations of the fetal heart rate
Uterine hyperstimulation Late decelerations of the fetal heart rate Rationale: Oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some obstetricians prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? Soft abdomen Uterine tenderness Absence of abdominal pain Painless, bright red vaginal bleeding
Uterine tenderness-Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.
A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? Place the woman in a high-Fowler's position. Palpate and evaluate contractions while administering a tocolytic. Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. Start an intravenous (IV) line with fluids to be administered at a keep-vein-open (KVO) rate only.
Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline-When an umbilical cord is protruding, nursing actions are immediately directed at reducing cord compression and facilitating delivery of the fetus. The cord is wrapped loosely in a sterile towel saturated with warm normal saline to prevent it from drying out and becoming compressed. The client is placed in an extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression. A tocolytic is used for inadequate uterine relaxation. IV solutions are administered at a rate greater than a KVO rate.