unit 1 + 2 exam review
A number of routine screens are performed on the pregnant client during the course of her gestation. what is the correct order the sequence of their testing.
1.Sickle cell screening 2.Alpha-fetoprotein (AFP) testing for neural tube defects 3.Serum glucose for gestational diabetes 4.Fetal movement test 5.Group B streptococcus culture
A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding?
abruptio placentae - Abruptio placentae is associated with cocaine use; it occurs in the third trimester
The nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. Which prophylactic medication does the nurse anticipate administering during the intrapartum period? -Diuretic -Antibiotic -Cardiotonic -Anticoagulant
antibiotic Clients who have mitral valve stenosis are administered prophylactic antibiotic therapy to minimize the development of streptococcal infections that may cause endocarditis. A diuretic will probably be used if heart failure develops. A cardiotonic will probably be used if heart failure develops. An anticoagulant will probably be used if thrombophlebitis or atrial fibrillation develops.
While conducting prenatal teaching, the nurse should explain to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase? Decreased metabolic rate Increased production of estrogen Secretion from the Bartholin glands Supply of sodium chloride to the vaginal cells
increased production of estrogen Increased estrogen production during pregnancy causes hyperplasia of the vaginal mucosa, which leads to increased production of mucus by the endocervical glands. The mucus contains exfoliated epithelial cells. Increased (not decreased) metabolism leads to systemic changes, but does not increase vaginal discharge. The amount of secretion from the Bartholin glands, which lubricates the vagina during intercourse, remains unchanged during pregnancy. There is no additional supply of sodium chloride to the vaginal cells during pregnancy.
A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? -Kidney defects -Cardiac anomalies -Neural tube defects -Urinary tract anomalies
neural tube defects The alpha-fetoprotein test can detect not only neural tube defects, but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.
A false-negative home pregnancy test may result if the woman does what when performing the test? Saturates the test strip Performs it in the first void of the morning Performs it 3 days after intercourse took place Performs it while taking a prescribed tranquilizer
performs it 3 days after intercourse took place The most common error made by women taking home pregnancy tests is to perform the test too early in the pregnancy. Although some tests may be accurate at 7 days, the test will be more accurate if performed at the time of the missed period. Saturation of the test strip and using the first void of the morning are necessary steps in the process. Taking a prescribed tranquilizer is more likely to cause a false-positive result.
A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by what? -Atony of the detrusor muscle -Compression by the enlarging uterus -Compromise of the autonomic reflexes -Narrowing of the ureteral entrance at the trigone
compression by the enlarging uterus The uterus and bladder occupy the pelvic cavity and lie closely together; as the uterus enlarges with the growing fetus, it impinges on the space occupied by the bladder, diminishing bladder capacity. Atony does not cause frequency; more likely it will lead to retention. Compromise of the autonomic reflexes will lead to incontinence rather than frequency. Narrowing of the ureteral entrance at the trigone is unlikely; the uterus does not impinge on this area.
A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy? -Fetal growth -Fluid retention -Metabolic alterations -Increased blood volume
fetal growth Weight gain during pregnancy averages 25 to 35 lb (11.3 to 15.9 kg). Of this amount, the fetus accounts for 7 to 8 lb (3.2 to 3.6 kg), or approximately 30%. Fluid retention accounts for 20% to 25% of weight gain. Metabolic alterations do not cause weight gain. Increased blood volume accounts for 12% to 16% of weight gain.
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect both diet and insulin needs. How should the nurse respond? -Insulin needs will decrease; the excess glucose will be used for fetal growth. -Diet and insulin needs won't change, and maternal and fetal needs will be met. -Protein needs will increase, and adjustments to insulin dosage will be necessary. -Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring.
insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring. Insulin requirements may decrease in early pregnancy because of increased fetal needs for nutrients and the possibility of maternal nausea and vomiting. Insulin requirements increase in the second and third trimesters as resistance to insulin develops. The blood glucose level is monitored to prevent ketoacidosis and harm to both the mother and fetus. Telling the client that protein needs will increase and adjustments to the insulin dosage will be necessary conveys information that is true only during early pregnancy. Even the nondiabetic woman makes dietary adjustments necessary to keep pace with the increased nutritional demands of pregnancy; in addition, insulin requirements increase in the second and third trimesters. Most nutrient requirements, not just protein, increase during pregnancy.
The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? -Clear, dark amber colored, and containing shreds of mucus -Straw-colored, clear, and containing little white specks -Milky, greenish yellow, and containing shreds of mucus -Greenish yellow, cloudy, and containing little white specks
straw-colored, clear and containing little white specks By 36 weeks' gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.
The nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate? -Hypotension -Decreased fetal heart rate -Unusual uterine enlargement -Painless, heavy vaginal bleeding
unusual uterine enlargement The proliferation of trophoblastic tissue filled with fluid causes the uterus to enlarge more quickly than if a fetus were in the uterus. Hypertension, not hypotension, often occurs with a molar pregnancy. There is no fetus within a hydatidiform mole. There may be slight painless vaginal bleeding.
A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur? -Sixth -Twelfth -Sixteenth -Eighteenth
sixth In the sixth week the fallopian tube can no longer expand to accommodate the size of the growing embryo. A tubal pregnancy cannot advance to the twelfth, sixteenth, or eighteenth week, because the tube cannot expand to accommodate the growing fetus.
Which pregnant client does the nurse suspect is most likely to have placenta previa? -19 years old, gravida 1, para 0 -30 years old, gravida 6, para 5 -25 years old, gravida 2, para 1 -40 years old, gravida 3, para 2
30 years old, gravida 6, para 5 Multiple past pregnancies can scar the endometrial lining, rendering it vulnerable to an abnormal implantation. Primigravidas are the least prone to placenta previa; the endometrium is receptive to implantation. Two pregnancies have not compromised the endometrium to the extent that an abnormal implantation is likely to occur. Age is known to be a significant factor; but, three pregnancies should not have compromised the endometrium.
While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information? -G5 T1 P1 A2 L2 -G4 T1 P1 A2 L2 -G4 T2 P0 A0 L2 -G5 T2 P1 A1 L2
G5 T1 P1 A2 L2 The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions.
The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? -Postpartum hemorrhage is an expected complication. -Perinatal mortality is two to three times more likely in multiple than in single births. -Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. -Maternal mortality is higher during the prenatal period in the setting of multiple gestation
Perinatal mortality is two to three times more likely in multiple than in single births. Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.
During a prenatal examination the nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for what? -Acute hemolytic anemia -Respiratory distress syndrome -Protein metabolism deficiency -Physiological hyperbilirubinemia
acute hemolytic anemia When an Rh-negative woman carries an Rh-positive fetus, there is a risk for the formation of maternal antibodies against Rh-positive blood; antibodies cross the placenta and destroy the fetal red blood cells. Determination of the lecithin/sphingomyelin ratio or the phosphatidylglycerol test, not the Rh factor, may provide information regarding the risk for respiratory distress syndrome (RDS). Testing for the Rh factor will not provide information about protein metabolism deficiency. Physiological bilirubinemia is a common occurrence in newborns; it is not associated with the Rh factor.
A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus to be where? -Even with the umbilicus -Just above the symphysis pubis -Two fingerbreadths above the umbilicus -Halfway between the symphysis and umbilicus
even with the umbilicus Around the 22nd week of gestation the top of the fundus is at the level of the umbilicus. Just above the symphysis pubis is too low for a pregnancy between the fifth and sixth months of gestation. Two fingerbreadths above the umbilicus is too high for 20 to 22 weeks' gestation. Halfway between the symphysis pubis and umbilicus is too low for a pregnancy between the fifth and sixth months of gestation.
A client in her tenth week of pregnancy exhibits presumptive signs of pregnancy. Which clinical findings may the nurse determine upon assessment? Select all that apply. -Amenorrhea -Breast changes -Urinary frequency -Abdominal enlargement -Positive urine pregnancy test
amenorrhea, breast changes, urinary frequency The key to answering this question is understanding the difference between presumptive versus probable signs of pregnancy. Presumptive signs of pregnancy are less specific subjective changes that are reported by the client during an assessment interview. Probable signs of pregnancy are more objective changes that can be measured in the reproductive organs during a physical assessment. The absence of menstruation (amenorrhea) is a presumptive sign of pregnancy that is recognized at 4-weeks' gestation. Breast changes, related to increased levels of estrogen and progesterone, are a presumptive sign of pregnancy that is recognized at 3- to 4-weeks' gestation. Urinary frequency, related to pressure of the enlarging uterus on the urinary bladder, is a presumptive sign of pregnancy that is recognized at 6- to 12-weeks' gestation. Abdominal enlargement related to the enlarging uterus is a probable sign of pregnancy that is recognized when the enlarging uterus rises out of the pelvis at 14- to 16-weeks' gestation. A positive urine pregnancy test result, indicating an increase in human chorionic gonadotropin (hCG), is a probable sign of pregnancy that can be detected 26 days after conception.
The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? Calling the primary healthcare provider Checking the client's reflexes Determining the client's blood type Administering the prescribed intravenous (IV) normal saline
checking the clients reflexes The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.
A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? -Taking exogenous insulin stimulates fetal growth. -Consuming more calories covers the insulin secreted by the fetus. -Extra circulating glucose causes the fetus to acquire fatty deposits. -Fetal weight gain increases as a result of the common response of maternal overeating
extra circulating glucose causes the fetus to acquire fatty deposits It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, where it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases because pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.
During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response? -That's fine as long as you include a variety of foods daily. -It's a good idea for you to keep your weight down during your pregnancy. -If you add 340 calories a day to your regular diet, you won't become overweight. -Gain no more than 25 lb (11 kg) so that it'll be easier to lose the weight after the baby is born
if you add 340 calories a day to your regular diet, you won't become overweight. Weight reduction is not advised during pregnancy; an additional 340 calories a day during the second trimester is recommended. When the client reaches the third trimester, another 120 calories should be added to her diet. A pregnant woman should not diet during pregnancy. Advising the client to eat a variety of foods provides insufficient information. The client should increase her protein and calorie intake during pregnancy. Dieting during pregnancy is harmful; the fetus may be deprived of essential nutrients. The client should not be limited to a specific weight gain. There is no specific recommendation for the amount of weight a pregnant woman should gain. However, 25 to 30 lb (11 to 16 kg) is the average generally suggested; this figure is based on the recommended caloric intake during pregnancy and the client's pre-pregnancy weight and metabolic rate.
A client attending a class in preparation for childbirth states, "I am sick and tired of wearing these same old clothes. I just wish all this would be over and done with." What is the nurse's most therapeutic response? -Most women feel the same way you do at this time. -You sound discouraged. Is there something bothering you? -Yes, this is the most uncomfortable time during pregnancy. -I understand how you feel. What do you know about labor?
most women feel the same way you do at this time Near term, most mothers are tired of the pregnant state and anxious for labor to begin; it is helpful for the client who feels this way to know that this is a common reaction. The client has just told the nurse what is bothering her; the response does not encourage the client to discuss her feelings further. Stating that this is the most uncomfortable time during pregnancy does not encourage further verbalization; instead, it closes off communication. Asking the client what she knows about labor narrows the client's verbalization to what the nurse believes is the client's area of concern.
The nurse is assessing a pregnant client during the third trimester. Which clinical finding is expected in the later stages of pregnancy? -Tachycardia -Dyspnea at rest -Progressive dependent edema -Shortness of breath on exertion
shortness of breath on exertion Shortness of breath on exertion is an expected cardiopulmonary adaptation during pregnancy caused by an increased ventricular rate and elevated diaphragm. Tachycardia, dyspnea at rest, and progressive dependent edema are pathologic signs of impending cardiac decompensation.
A pregnant client in the third trimester tells the nurse in the prenatal clinic that she is experiencing heartburn after every meal. Which explanation should the nurse provide regarding the cause of the heartburn? -The esophageal sphincter relaxes and allows acid to be regurgitated. -In pregnancy, gastric motility increases, causing a burning sensation. -In pregnancy, gastric pH increases, causing acid to enter the esophagus. -In pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine.
the esophageal sphincter relaxes and allows acid to be regurgitated Relaxation of the esophageal sphincter, resulting in regurgitation of acid, causes heartburn (pyrosis) during the second half of pregnancy. Delayed emptying of stomach contents because of decreased gastric motility and displacement of the stomach because of uterine enlargement contribute to the problem. Gastric motility is decreased during pregnancy. When gastric pH increases, gastric juices become more alkaline, leaving little or no acid to be regurgitated into the esophagus. The pyloric sphincter does not relax, and acid does not pass into the small intestine.
A client tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her history reveals amenorrhea for the last 2 months and pregnancy confirmation after her first missed period. What type of abortion is suspected? -Missed -Inevitable -Threatened -Incomplete
threatened Spotting in the first trimester may indicate that the client is having a threatened abortion; any client with the possibility of hemorrhage should not be left alone, so her admission to the hospital helps ensure her safety. A missed abortion may not cause any outward signs or symptoms, except that the signs of pregnancy disappear. An inevitable abortion can be confirmed only if vaginal examination reveals cervical dilation. With an incomplete abortion some, but not all, of the products of conception have been expelled.
Placenta previa is diagnosed when a client at 24 weeks' gestation presents with painless vaginal bleeding. The client is concerned that she has done something to cause the bleeding. How should the nurse respond? -"It's not your fault; these things happen." -"Don't worry; it's just a sign that labor is beginning." -"Your uterus may be weak—that's what causes the vaginal bleeding." -"You have a low-lying placenta that separates when the cervix dilates."
you have a low-lying placenta that separates when the cervix dilates Presenting facts helps reduce feelings of guilt. Stating that the bleeding is not the client's fault is an inadequate explanation that does not offer any information. Labor may not be starting at this time. Placenta previa can occur in a woman with a healthy uterus.
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? -Placenta previa -Precipitous birth -Abruptio placentae -Breech presentation
abruptio placentae Abruptio placentae indicates a premature placental separation; the classic signs are abdominal rigidity, a tetanic uterus, and dark-red bleeding. Placenta previa occurs with a low-lying placenta and is manifested by painless bright-red bleeding. Information on cervical effacement, dilation, and station is required before the nurse can come to a conclusion regarding precipitous birth. Fetal presentation is not related to the client's signs and symptoms.
After performing Leopold maneuvers on a laboring client, the nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones? -Above the umbilicus in the midline -Above the umbilicus on the left side -Below the umbilicus on the right side -Below the umbilicus near the left groin
below the umbilicus on the right side Fetal heart tones are best auscultated through the fetal back. In this case the presenting part is in the right occiput posterior position; the back is below the umbilicus and on the right side. Above the umbilicus in the midline is the placement that should be used when the fetus is lying in the midline in a breech position. Placement above the umbilicus on the left side is appropriate when the fetus is in the left sacrum anterior position. Placement below the umbilicus near the left groin is appropriate when the fetus is in the left occiput anterior or left occiput posterior position.
During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? -Liver and raisins -Cheese and broccoli -Eggs and lean meats -Whole-wheat breads and cereals
cheese and broccoli The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content. Although liver and raisins, eggs and lean meats, and whole-wheat breads and cereals are recommended as part of a high-quality nutritional intake, they are inadequate sources of calcium.
The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next? Ambulating the client to promote circulation Inserting two small-bore intravenous catheters Determining whether the client feels safe at home Ensuring that the client has her glasses to ambulate
determining whether the client feels safe at home Bruising on the backs of both shoulders and both wrists indicates potential abuse; asking the client whether she feels safe at home will open a dialogue to discuss the possible physical abuse. Whether or not the client admits abuse, the nurse is required to report the finding. A client in preterm labor should have a large-bore intravenous catheter. Ambulation is not appropriate for a client in preterm labor, and bed rest should be maintained. Reporting should not be delayed.
A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take? -Discontinuing the test because the pattern is within the normal range -Encouraging the client to drink more fluids to decrease the fetal heart rate -Notifying the primary healthcare provider and preparing for an emergency birth -Recording this nonreassuring pattern and continuing the test for further evaluation
discontinuing the test because the pattern is within the normal range The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.
Which recommendation should the nurse provide a client with fluid retention during pregnancy? -Decrease fluid intake. -Maintain a high-sodium diet. -Elevate the lower extremities. -Ask the healthcare provider for a diuretic
elevate the lower extremities Elevation of the extremities several times daily is recommended to ease dependent edema. Fluid intake should be encouraged because adequate hydration maintains fluid and electrolyte balance. The client should not maintain a high-sodium diet because of the fluid retention. Sodium intake should be limited, but not completely restricted, because it is necessary in order to balance the increased fluid volume needs during pregnancy. Diuretics can be harmful and are not used during a healthy pregnancy.
After an incomplete abortion, a client tells the nurse that although her primary healthcare provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse? -"I don't think you should focus on this anymore." -"It's when the fetus dies but is retained in the uterus for at least 2 months." -"It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." -"I think it's best for you to ask your primary healthcare provider for the answer to that question."
it's when the fetus is expelled but other parts of the pregnancy remain in the uterus A correct and simple definition answers the question and fulfills the client's need to know. Telling the client not to focus on the topic any more denies the client's right to know. The definition of a missed abortion is when the fetus dies but is retained in the uterus for at least 2 months. Telling the client to ask her primary healthcare provider for the answer is an abdication of the nurse's responsibility; the nurse can independently reinforce information and correct misconceptions.
A pregnant client has class II cardiac disease. To best plan the client's care, what does the nurse anticipate for the client? -May participate in as much activity as she desires -Should be hospitalized if there is evidence of cardiac decompensation -Will have to maintain bed rest for most of the day throughout her pregnancy -May have to consider a therapeutic abortion if there is evidence of cardiac decompensation
should be hospitalized if there us evidence of cardiac decompensation Clients with cardiac disease should be taught the signs and symptoms of cardiac decompensation; if they occur, the client should stop the activity that precipitated them and notify the primary healthcare provider. Participating in as much activity as she desires is acceptable behavior for a client with class I cardiac disease. Maintaining bed rest is the treatment for a client with class III cardiac disease. Considering a therapeutic abortion is the recommendation for a client with class IV cardiac disease.
The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of most concern to the nurse? -Continued bloody show -Cervical dilation of 4 cm -Contractions every 4 minutes -Spontaneous rupture of membranes 3 hours ago
spontaneous rupture of membranes 3 hours ago Rupture of the membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus. GBS infection is a leading cause of neonatal morbidity and mortality. Continued bloody show, cervical dilation of 4 cm, and contractions every 4 minutes are all normal findings for a client in labor.
Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. What should the nurse do next? -Stop the infusion of magnesium sulfate and notify the primary healthcare provider. -Administer calcium gluconate, because it is an antidote to magnesium sulfate. -Continue the magnesium sulfate infusion, because the blood pressure is still high. -Check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary
stop the infusion of magnesium sulfate and notify the primary HCP Near-toxic levels of magnesium sulfate are suggested by the disappearance of the knee-jerk reflex and by depressed respirations (fewer than 12 breaths/min). This is a life-threatening situation, and the primary healthcare provider must be notified immediately. Calcium gluconate may be given as an antidote, but the infusion of magnesium sulfate must be stopped first. Magnesium sulfate is not an antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention.
A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.8 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response? -You have not gained enough weight. Can you increase your daily intake of calories? -Your weight is not a concern. I'll refer you to the dietitian, who will review your diet. -You've gained too much weight for 23 weeks' gestation. Are your rings getting tight? -Your weight is expected for someone at 23 weeks' gestation. Continue your current diet
your weight is expected for someone at 23 weeks gestation. continue your current diet. The recommended average weight gain is 2.2 to 5.5 lb (1 to 2.5 kg) during the first 12 weeks, then approximately 1 lb (0.45 kg) per week until birth; 14 to 16 lb (6.4 to 7.3 kg) is an appropriate weight gain at 23 weeks' gestation. Stating that the client has not gained enough weight is inaccurate information. Stating that the weight is not a concern dismisses the client's concern; also, the nurse is abdicating the responsibility for teaching by the referral to the dietitian. Stating that the client has gained too much weight for 23 weeks' gestation is inaccurate information that may produce anxiety. It implies that the client may have preeclampsia.
