Review_MATERNITY

A nurse is collecting data on a client who is pregnant with twins. Which of the following signs would alert the nurse to a potential problem specifically related to the twin pregnancy? 1.Hypertension 2. Elevated blood glucose levels 3. Uterine size is large for gestational age 4. Mother is confirmed as blood type Rh negative

1.Hypertension Rationale: The mother with a multiple-gestation pregnancy is at a higher risk for preeclampsia than if she had a singleton pregnancy. Mother should be monitored for signs and symptoms of preeclampsia and preterm labor. A classic sign of preeclampsia is hypertension. An elevated blood glucose level and Rh sensitization are concerns but are not unique to a multiple pregnancy. Uterine size may be large for gestational age in a multiple-gestation pregnancy.

A nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at gestational week: 1. 1. 5 2. 10 3. 16 4. 20

4. 20 Rationale: The fetal heart rate can first be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound device is used, the fetal heart rate can be detected as early as 10 weeks of gestation.

A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse determines that: 1.The client has the herpes simplex virus. 2. HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test. 3. The newborn infant will have this disease at birth. 4. This client has contracted an airborne disease.

2. HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test. Rationale: Diagnosis depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA test. Options 1 and 4 are incorrect because HIV occurs primarily through the exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk of developing this infection.

A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes? 1.Well, I guess I will just have to deal with this." 2. "Oh, well, I guess this isn't the end of the world." 3."I shouldn't have eaten so many sweets before I became pregnant." 4. "I have heard that this type of diabetes is first discovered during pregnancy."

3."I shouldn't have eaten so many sweets before I became pregnant." Rationale: Gestational diabetes is not necessarily caused by eating too many sweets before pregnancy. Options 1 and 2 indicate a common normal response. Option 4 is an accurate statement. Option 3 is the only option that indicates a knowledge deficit.

A nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is: 1.Oxytocin 2. Prolactin 3. Progesterone 4. Testosterone

2. prolactin Prolactin stimulates the secretion of milk, called "lactogenesis." Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.

Magnesium sulfate is prescribed for a client with severe preeclampsia. Which statement by the student nurse supports the need for further education regarding the action of this medication? 1."It produces flushing and sweating as a result of decreased peripheral blood pressure." 2. "It decreases the central nervous system responses, acting as an anticonvulsant." 3."It increases acetylcholine and blocks neuromuscular transmission." 4. "It decreases the frequency and duration of uterine contractions."

3."It increases acetylcholine and blocks neuromuscular transmission Rationale: Magnesium sulfate produces flushing and sweating as a result of decreased peripheral blood pressure; decreases the central nervous system responses and acts an anticonvulsant; decreases the frequency and duration of uterine contractions; and decreases acetylcholine, blocking neuromuscular transmission.

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following informative statements will the nurse provide to the client? 1."The test is an invasive procedure and requires that you sign an informed consent." 2. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 3."An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." 4. "The fetus is challenged by uterine contractions to obtain the necessary information."

3."An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." Rationale: The nonstress test takes about 30 to 40 minutes. The test is termed "nonstress" because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded.

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving? 1.Urinary output has increased. 2. There is no evidence of dependent edema. 3.The client complains of a headache and blurred vision. 4. The blood pressure reading has returned to the prenatal baseline.

3.The client complains of a headache and blurred vision. Rationale: Options 1, 2, and 4 are all signs that the GH is being resolved. Option 3 is a symptom of the worsening of the GH.

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: 1.Avoid rotating breast-feeding positions. 2. Stop nursing until the nipples heal. 3. Substitute a bottle-feeding until the nipples heal. 4.Begin feeding on the less sore nipple.

4. Begin feeding on the less sore nipple. Rationale: The nurse would instruct the mother to begin feeding on the less sore nipple. The infant sucks with greater force at the beginning of feeding. Rotating breast-feeding positions, breaking suction with the little finger, nursing frequently, not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness. Options 1, 2, and 3 are incorrect measures.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is: 1.The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity 3. The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/DAY

4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day Rationale: Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately one fingerbreadth or 1 cm per day. The other options do not accurately describe involution.

A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates a need for further instruction? 1. I need to take the antibiotics as prescribed." 2. "I need to apply warm compresses to provide comfort." 3. "I need to take warm sitz baths to promote healing." 4."I need to isolate my infant for 48 hours after the starting the antibiotics

4."I need to isolate my infant for 48 hours after the starting the antibiotics Rationale: Broad-spectrum antibiotics will be prescribed for the mother, and the mother should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles.

A nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which of the following would the nurse check first? 1.Pulse 2. Weight 3. Temperature 4. Abdominal girth measurement

1.Pulse Rationale: The primary concern when ectopic pregnancy is suspected is the occurrence of bleeding and hypovolemic shock. Option 1 is the only assessment that would provide information related to this occurrence. An elevated pulse is an indicator of shock. The nurse should also monitor for decreasing hematocrit levels and pain. Options 2, 3, and 4 do not provide data that would indicate the occurrence of hypovolemic shock.

A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include: 1.Hypotonic contractions 2. Shoulder dystocia 3. Primigravidity 4. Weak bearing-down efforts

2. shoulder dystocia Rationale: Shoulder dystocia at delivery causes increased pressure in the thin lower uterine segment and subsequently the risk for spontaneous rupture. Statistically, rupture is more common in multigravidas, especially when combined with the use of oxytocin. Hypotonic contractions and weak bearing-down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.

A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection? 1.A 33-year-old gravida III 2. An adolescent with multiple heterosexual contacts 3. A 25-year-old client with a history of spontaneous abortions 4. A multigravida with a history of repeat cesarean deliverie

2.An adolescent with multiple heterosexual contacts Rationale: Although all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors. The client profiles in options 1, 3, and 4 identify at-risk situations for a variety of obstetric risk factors but not necessarily HIV infection.

A nurse is caring for a woman who is being treated with antibiotics for mastitis. The nurse reinforces instructions and tells the woman to: 1.Stop breast-feeding. 2.Complete the entire antibiotic regimen. 3. Avoid wearing a bra. 4. Avoid taking analgesics.

2.Complete the entire antibiotic regimen. Rationale: If antibiotics are prescribed, the client must complete the regimen even though symptoms will be reduced in 24 to 48 hours. Options 1, 3, and 4 are inappropriate treatment measures for mastitis. The client should breast-feed, wear a supportive bra, and take analgesics as prescribed.

The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to: 1.Eliminate between-meal snacks. 2.Drink decaffeinated coffee and tea. 3. Lie down for 30 minutes after eating. 4. Substitute salt in cooking for other spices.

2.Drink decaffeinated coffee and tea. Rationale: Spices tend to trigger heartburn. Caffeine, like spices, may cause heartburn and needs to be avoided. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.

The nurse is collecting data during the admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as: 1,G = 3, T = 2, P = 0, A = 0, L = 1 2.G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2.G = 2, T = 1, P = 0, A = 0, L = 1 Rationale: Pregnancy outcomes can be described with the GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

A nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action would be appropriate? 1.Obtain a hemoglobin and hematocrit level. 2.Instruct the mother to request help when getting out of bed. 3. Elevate the head of the bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of lightheadedness and dizziness have subsided.

2.Instruct the mother to request help when getting out of bed. Rationale: Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness and dizziness are signs that caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times getting out of bed. Option 1 requires a health care provider's prescription. Option 3 is not a helpful action. Option 4 is unnecessar

A nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage, as a result of this condition. The nurse plans care based on what information related to the condition? 1.It will cause increased uterine contractions post-delivery. 2. Increased vaginal secretions will prevent the site from healing properly. 3.Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. 4. Sexual intercourse before 6 weeks postpartum will significantly increase the risk for infection.

3.Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. Rationale: In placenta previa, the placenta is in the lower segment of the uterus near or over the internal cervical os. After delivery, the muscle tissue in that segment has fewer muscle fibers and the weak contractions cannot compress the open vessels at the site. Infection is a high risk because the placenta site is located near the vagina, and any vaginal organisms can easily travel to the uterus, causing infection. Options 1, 2, and 4 are incorrect.

A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to: 1. A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:

4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours. Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection? 1.Proteinuria of 3+ 2. Presence of deep tendon reflexes 3. Serum magnesium level of 6 mEq/L 4. Respirations of 10 breaths per minute

4. Respirations of 10 breaths per minute Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which of the following responses, if made by the student, indicates an understanding of the function of this hormone? 1."It softens the muscles and joints of the pelvis." 2. "It is the primary hormone of milk production." 3. "It increases during pregnancy to stimulate the basal metabolic rate." 4."It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."

4."It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus." Rationale: Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus. Relaxin is the hormone that softens the muscles and joints of the pelvis during labor. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production

Abdominal ultrasonography is prescribed for a woman who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement to the woman? 1."The procedure will take about one hour." 2. "You will be positioned on your side with your head flat." 3. "You need to be sure to urinate before the procedure." 4. "You will be positioned on your back and turned slightly to one side with your head elevated."

4."You will be positioned on your back and turned slightly to one side with your head elevated." Rationale: In placenta previa, the placenta is in the lower segment of the uterus near or over the internal cervical os. After delivery, the muscle tissue in that segment has fewer muscle fibers and the weak contractions cannot compress the open vessels at the site. Infection is a high risk because the placenta site is located near the vagina, and any vaginal organisms can easily travel to the uterus, causing infection. Options 1, 2, and 4 are incorrect.

A nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which of the following would be a part of the teaching plan for this class? 1.Use of over-the-counter medications 2. Fetotoxic substances in the workplace 3. Effects of secondary cigarette smoke on the fetus 4.Travel precautions and use of shoulder seat belts

4.Travel precautions and use of shoulder seat belts Rationale: Placental separation as a result of uterine distortion can occur from trauma, such as in car accidents and decreases or shuts off uteroplacental circulation. Partial placental separation will also result in fetal distress, with the amount of distress depending on the degree of separation. Complete separation leads to sudden severe fetal distress followed by fetal death. Use of the shoulder seat belt decreases the risk of placental separation by preventing the traumatic flexion of the woman's body from sharp braking or impact, if an accident occurs. Although options 1, 2, and 3 are important teaching points, they are not related to physical trauma affecting the fetus