Saunders Focus on Maternity Exam

The nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder?

"Do you have sharp pain on the right or left side of your pelvis?"

The nurse is caring for a client receiving an intravenous infusion of oxytocin to stimulate labor. Which finding would prompt the nurse to stop the infusion?

Nonreassuring fetal heart rate pattern

A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. Based on this observation, what is the most appropriatenursing action?

Notifying the primary health care provider

The delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. Based on this finding, which nursing action is appropriate initially?

Notifying the primary health care provider

The nurse is teaching a pregnant client about measures to strengthen the pelvic floor. What does the nurse instruct the client to do?

Perform Kegel exercises in 10 repetitions, three times per day

The nurse provides instruction regarding prenatal care to a client with a history of heart disease. What does the nurse tell the client?

Physical activity should be limited

A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, what does the nurse determine that the client may be experiencing?

Placenta previa

A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. What does the nurse tell the client?

That this is a normal postpartum occurrence

The nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective?

The client experiences diuresis within 24 to 48 hours.

After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which conclusion should the nurse make?

The client is experiencing low self-esteem.

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. What does the nurse tell the client?

The infant should receive both the vaccine and hepatitis immune globulin soon after birth

A rubella antibody screen is performed on a pregnant client, and the results indicate that the client is not immune to rubella. What does the nurse tell the client to do?

A rubella vaccine must be administered after childbirth

A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures?

"I need to drink at least 2000 mL of fluid a day."

A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction?

"I need to stay in bed for the rest of my pregnancy."

The postpartum nurse instructs a new mother in how to bathe her newborn son. Which statement by the mother indicates a need for further instruction?

"I should bathe him after a feeding."

During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb (4.5 kg) during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't eat regular meals." What is the nurse's most appropriate response?

"Let's make a list of what you're eating."

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears?

"Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today."

A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. What is the most appropriate response?

"The newborn does have a risk of contracting the infection."

A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?

"This must be hard for you."

A pregnant client is seen in the clinic for the first time. This is the client's first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply.

-"I need to limit my exercise while I'm pregnant." -"I'll come back for a prenatal visit every month during my first trimester."

The nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply.

-A client with septicemia -A client who had a cesarean section because of abruptio placentae

A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device?

12 weeks

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. What does the nurse analyze the client's behavior as most likely the result of?

Anxiety and the need for support

The nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant?

A copper-colored rash

Rho(D) immune globulin is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history. Which finding is a contraindication to administration of the medication?

A previous hypersensitivity reaction to immune globulin

The nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. Based on this finding, which nursing action is the priority?

Administering oxygen by way of face mask

After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. What does the nurse immediately prepare to do?

Assist in repositioning the uterus through the vagina into a normal position

A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL (8.6 mmol/L). What does the nurse tell the client?

Additional tests will likely be performed to confirm gestational diabetes

A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). What should the nurse immediately do?

Administer oxygen to the woman

The nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure monitor that the woman's pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. What does the nurse interpret these findings as indications of?

Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome)

A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. What does the nurse tell the client?

Alternating contraction and relaxation of the muscles of the perineal area should be practiced

The nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?

Apple and whole-grain toast

The nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. What does the nurse tell the mother to do?

Apply oil to the affected area on the infant's scalp

The nurse is teaching a pregnant client about the expectations and complications of pregnancy and is describing Braxton Hicks contractions. What does the nurse tell the client about these contractions?

Are a common occurrence of pregnancy

The nurse is preparing to perform the Leopold maneuvers on a pregnant client. What should the nurse do first?

Ask the client to empty her bladder

The nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. What does the nurse tell the client what to immediately do if signs/symptoms of hypoglycemia occur?

Check her blood glucose level

The nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn?

Bowel sounds heard over the chest

A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediatelyprepares for the administration of:

Calcium gluconate

The nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin stimulation. What does the nurse determine that the client's behavior may be a result of?

Concern about her own and the baby's well-being

A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, what is the most appropriate nursing action?

Contact the primary health care provider

The nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the primary health care provider?

Diaphoresis and tachycardia

A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. What does the nurse recognize this volume of urine output as an indication of?

Diminished edema and vasoconstriction in the brain and kidneys

The nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse perform in response to this observation?

Documenting the finding

The nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which information related by the client would the nurse give the highest priority?

Drinking less than 4 glasses of fluid daily

The home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. What does the nurse tell the client to do?

Eat carbohydrates such as cereals, rice, and pasta

A woman is being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort?

Eat dry crackers every 2 hours to prevent an empty stomach

The nurse is teaching a new mother how to perform umbilical cord care and how to recognize the signs/symptoms of a cord infection. Which finding does the nurse tell the mother is an indicator of infection?

Edema at the base of the cord

The nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). What is the most appropriate nursing action?

Encourage the intake of oral fluids

The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. What does the nurse tell the mother to do?

Gently massage the breasts during breastfeeding to help empty the breasts

A nurse is caring for a postpartum client who had a low-lying placenta. What does the nurse assess the client most closely for?

Hemorrhage

A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care?

History of IV drug use

When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure? (Picture indicates uterine fundus at the level of the umbilicus)

Immediately after delivery

A postpartum client asks a nurse when she may safely resume sexual activity. What does the nurse tell the client when she may resume sexual activity?

In 2 to 4 weeks

The nurse, performing an assessment of a pregnant client is preparing to take the client's blood pressure. How does the nurse position the client?

In a sitting position with the arm in a horizontal position at heart level

The nurse is monitoring a pregnant client with sepsis for signs/symptoms of disseminated intravascular coagulopathy (DIC). Which laboratory finding causes the nurse to suspect DIC?

Increased fibrin degradation products

The clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?

Increased shortness of breath and bilateral crackles in the lungs

Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. What does the nurse initially do?

Instruct the mother to push when signs of separation have occurred

The nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry (Spo2) is 92%. What should the nurse do first?

Instructs the client to take several deep breaths

After the delivery of a newborn, the nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating what about the infant?

Is adjusting well to extrauterine life

The nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid?

Lima beans

The nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority?

Monitoring fetal status

A neonate is irritable, cries incessantly, and has a temperature of 99.4° F (37.4°C). The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. What does the nurse determine that these signs/symptoms are consistent with?

Neonatal abstinence syndrome

A nonstress test is performed, and the primary health care provider documents "accelerations lasting less than 15 seconds throughout fetal movement." How does the nurse interpret these findings?

Nonreactive

A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician's office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. What should the nurse immediately do?

Position the client on her side

A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. What is the nurse's most appropriate nursing action in this situation?

Preparing the client for a cesarean delivery

The nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which situation would the nurse suspect based on this observation?

Pressure on the fetal head during a contraction

The nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?

Prone

The nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client?

Providing pain relief

The nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate?

Rationale: Accelerations, shown in the correct answer, are brief temporary increases in the fetal heart rate of at least 15 beats/min from baseline and lasting at least 15 seconds. They are an indication of fetal well-being and an oxygenated fetal central nervous system. Variable decelerations do not have the uniform appearance of early or late decelerations. Early decelerations are decreases in the fetal heart rate to below baseline; late decelerations look similar to early decelerations but begin well after the contraction begins and return to baseline after the contraction ends.

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F (37.8° C), and the client reports that she last ate 2 hours ago. The client also states that "everything happened so fast" and that she has had no preparation for the cesarean delivery. Which action should the nurse take first?

Reporting the time of last food intake to the primary health care provider

A nurse is caring for a client in precipitous labor. In which position does the nurse place the client? Includes 4 pictures - A. Hands and knees B. Sitting Semi-Fowler in a bed with knees apart and feet together C. Sitting in a chair D. Side-lying or lateral Sims position

Side-lying or lateral Sims position

The nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, what should the nurse do?

Simultaneously provide pressure over the lower uterine segment

The nurse is monitoring a client in labor for signs/symptoms of intrauterine infection. Which sign/symptom, indicative of infection, would prompt the nurse to contact the primary health care provider?

Strong-smelling amniotic fluid

The delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table. How does the nurse position the client?

Supine with a wedge under the right hip

The nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the primary health care provider will prescribe?

T-lymphocyte determination

A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother to do what?

The mother may need to take isoniazid, pyrazinamide, and rifampin for a total of 9 months

The maternity nurse is caring for a pregnant client with no history of preeclampsia who is receiving a magnesium sulfate infusion. Why is this client receiving this infusion?

To halt preterm labor contractions

The nurse caring for a hospitalized client with a diagnosis of abruptio placentae develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs/symptoms of shock develop, to promote tissue oxygenation, what would the nurse immediately do?

Turn the client on her side

Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which finding would the nurse expect to note?

Uterine tender to palpation

The nurse is monitoring a fetal heart rate (FHR). How does the nurse document a reassuring FHR pattern in the record as noted as?

Variability of 6 to 25 beats/min

The nurse is admitting a newly pregnant client to the clinic. The client asks the nurse about gonorrhea. What are some appropriate responses by the nurse? Select all that apply.

-"Urinary frequency may occur." -"Transmission of this organism is by sexual intercourse." -"If infection is present, your partner must be treated, too." -"If you are at high risk for this infection, then another test should be repeated during your third trimester."

A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply.

-A hypertensive client -A pack-a-day smoker

The nurse is assisting the primary health care provider to perform a Fern test on a pregnant client. What are some manifestations of this test? Select all that apply.

-A microscopic slide test -Determines presence of amniotic fluid leakage -Fernlike pattern produced by effects of salts of amniotic fluid showing presence of amniotic fluid

The nurse is assisting a primary health care provider in performing a physical examination on a client who has just been told that she is pregnant. The nurse knows that what data indicate a positive sign of pregnancy? Select all that apply.

-Active fetal movements palpable by the examiner -An outline of the fetus by radiography or ultrasonography -Fetal heart rate detected by nonelectronic device (fetoscope) at 20 weeks of gestation

The nurse is caring for a post-partum client with suspected endometritis. What manifestations of this condition would the nurse expect to note? Select all that apply.

-Backache -Tender uterus -Foul-smelling lochia

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Select all that apply.

-Fetal bradycardia -Maternal tachypnea -Maternal complaint of sudden sharp abdominal pain

The nurse is caring for a client in labor who has sickle cell anemia. What are some situations that can precipitate sickling? Select all that apply.

-Fever -Dehydration -Emotional or physical stress -Any condition that increases or alters the need and transport of oxygen

The nurse educator is lecturing to a group of students about the probable signs of pregnancy. What signs does the nurse describe to the students? Select all that apply.

-Hegar's sign -Chadwick's sign -Uterine enlargement -Positive pregnancy test for the presence of hCG

The nurse is changing the diaper of a 1-day-old full-term female newborn. What assessment criteria of the labia does the nurse determine are normal? Select all that apply.

-Hymen tag may be visible -Labia may be edematous -Pseudomenstruation, caused by withdrawal of the maternal hormone estrogen, is possible (blood-tinged mucus)

The maternity nurse is assessing a client who has progressed to Stage 2 of labor. What findings does the nurse expect to assess? Select all that apply.

-Increase in bloody show -Mother feels urge to bear down -Progress of labor measured by descent of fetal head through birth canal or change in fetal station

The nurse is about to perform an assessment of a pregnant woman in the Labor Room. What does the nurse know about false labor? Select all that apply.

-Indentable uterus -No lightening of fetus -Contractions relieved after walking -Contractions felt in abdomen and groin

The nurse is assisting the primary health care provider with performing internal fetal monitoring. What are some manifestations of internal fetal monitoring? Select all that apply.

-Is invasive -Requires rupturing of the membranes -A second primary health care provider does not have to be present

The clinic nurse is examining a 16 week pregnant client for suspected abortion. What manifestations does the nurse expect to note? Select all that apply.

-Low uterine cramping or contractions -Blood clots or tissue through the vagina

The nurse is educating a newly pregnant client who states that this is her first pregnancy. What does the nurse tell the client about amniotic fluid? Select all that apply.

-Maintains the body temperature of the fetus -Surrounds, cushions, and protects the fetus and allows for fetal movement -Fetus modifies or changes the amniotic fluid through the processes of swallowing, urinating, and movement through the respiratory tract

A nurse is assessing a newborn infant with a diagnosis of gastroschisis. What are some problems associated with this condition? Select all that apply.

-Postoperatively, most infants are asymptomatic. -Surgery performed within several hours after birth. -Herniation of intestine is lateral to umbilical ring.

The nurse is assessing a newly delivered large for gestational age neonate. The nurse is aware of what manifestations of this neonate category? Select all that apply.

-Respiratory distress occurs -Increased risk for infection -Provide stimulation, such as touch and cuddling

The maternity nurse educator is lecturing to student nurses about respiratory physiological maternal changes. What maternal respiratory changes does the instructor state happen during pregnancy? Select all that apply.

-Shortness of breath may be experienced -Oxygen consumption increases by approximately 15% to 20%

The nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply.

-The infant has urinated. -The infant has passed 1 stool. -Vital signs are documented as normal.

A nurse assessing a pregnant client's deep tendon reflexes notes a reflex of 2+. What should the nurse do?

Document the finding

A nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which finding would prompt the nurse to contact the primary health care provider?

Respirations of 10 breaths/min