Unit 29 Complications in OB

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? a. Assess fetal heart sounds. b. Place the woman in Trendelenburg position. c. Administer oxygen at 10 L/min by face mask. d. Administer amnioinfusion.

a. Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin? a. STIs b. amniocentesis c. molar pregnancy d. maternal trauma

a. STIs Indications for Rho(D) immune globulin include isoimmunization, ectopic pregnancy, chorionic villus sampling, amniocentesis, prenatal hemorrhage, molar pregnancy, maternal trauma, percutaneous umbilical sampling, therapeutic or spontaneous abortion, fetal death, or fetal surgery.

A nurse is providing care for a pregnant client at 38 weeks' gestation who is considered a Class III cardiac risk for pregnancy. The health care team anticipates the client will have a spontaneous vaginal birth. The nurse anticipates assisting with which intervention(s) during the client's labor and birth? Select all that apply. a. Administer higher doses of oxytocin. b. Assist in the placement of epidural anesthesia. c. Assist in the use of a vacuum extractor. d. Coach the client in Valsalva pushing. e. Position the client in a supine position for birth.

b. Assist in the placement of epidural anesthesia. c. Assist in the use of a vacuum extractor. The nurse anticipates assisting with the placement of an epidural for pain relief during labor and the use of a vacuum extractor during the birth. Oxytocin can be used with these clients, but at the lowest effective dose to minimize hemodynamic effects in the pregnant client. Valsalva (or closed-glottis) pushing is discouraged but open-glottis pushing may be used depending on the clinical situation. Positioning in the lateral, not supine, position will provide optimal placental perfusion, and reduce oxygen needs.

A student nurse is preparing for a presentation that will illustrate the various physiologic changes in the woman's body during pregnancy. Which cardiovascular changes up through the 26th week should the student point out? a. Decreased pulse rate and increased blood pressure b. Increased pulse rate and decreased blood pressure c. Increased pulse rate and blood pressure d. No change in pulse rate or blood pressure

b. Increased pulse rate and decreased blood pressure Pulse rate frequently increases during pregnancy, although the amount varies from a slight increase to 10 to 15 beats per minute. Blood pressure generally decreases slightly during pregnancy, reaching its lowest point during the second trimester.

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? a. Administer an analgesic to the client. b. Prepare the client for a cesarean birth. c. Prepare for a precipitous vaginal birth. d. Prepare to assist the care provider with an amniotomy.

b. Prepare the client for a cesarean birth. If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed? a. bronchodilators b. tocolytic therapy c. muscle relaxants d. anti-anxiety therapy

b. tocolytic therapy Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity.

A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about the prescribed iron supplement, which statement indicates successful teaching? a. "I should take my iron with milk." b. "I should avoid drinking orange juice." c. "I need to drink plenty of fluids to prevent constipation." d. "I will call the health care provider if my stool is black and tarry."

c. "I need to drink plenty of fluids to prevent constipation." Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids. Milk inhibits absorption and should be discouraged. Vitamin C-containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify the health care provider.

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? a. placental separation b. aspiration c. amniotic fluid embolism d. congestive heart failure

c. amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.

The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart sounds? a. low in the abdomen b. left lateral abdomen c. high in the abdomen d. right lateral abdomen

c. high in the abdomen With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral abdominal regions.

A woman in labor is experiencing dysfunctional labor (hypotonic uterine dysfunction). Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? a. sedatives b. tocolytics c. uterine stimulants d. corticosteroids

c. uterine stimulants For dysfunctional labor (hypotonic uterine dysfunction), a uterine stimulant such as oxytocin may be prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate? a. "You'll probably have a cesarean birth to prevent exposing your newborn." b. "Antibodies cross the placenta and provide immunity to the newborn." c. "Wait until after the infant is born, and then something can be done." d. "Antiretroviral medications are available to help reduce the risk of transmission."

d. "Antiretroviral medications are available to help reduce the risk of transmission." Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of birth should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Waiting until after the infant is born may be too late.

A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem? a. The fetus is macrosomic. b. The mother is fighting the contractions. c. The mother has a small pelvic opening. d. Uterine contractions are weak and ineffective.

d. Uterine contractions are weak and ineffective. Labor dystocia indicates that the labor is progressing too slowly. Reasons for this are described as due to the "four P's", which are passageway, passenger, power and psyche. A power problem involves either ineffective contractions in either quality or quantity or the mother is too tired to push when needed.

What is the best indicator that the client is experiencing an ectopic pregnancy? a. increasing hematocrit and hemoglobin levels b. amenorrhea c. nausea d. adnexal tenderness

d. adnexal tenderness Ectopic pregnancy occurs when the fertilized ovum is slowed or prevented passage through the fallopian tube and implants before it reaches the uterus, usually in the adnexa (ovaries/fallopian tubes). When the embryo outgrows space, the area ruptures and there is bleeding. This bleeding irritates the peritoneum causing sharp, one-sided adnexal tenderness or pain. Laboratory tests reveal decreased hematocrit and hemoglobin levels and rising leukocyte levels. Initially symptoms of pregnancy may be present, including amenorrhea, breast tenderness, and nausea.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? a. first degree b. second degree c. third degree d. fourth degree

d. fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? a. oxytocin b. promethazine c. ondansetron d. methotrexate

d. methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available? a. calcium gluconate b. potassium chloride c. ferrous sulfate d. calcium carbonate

a. calcium gluconate The woman is at risk for magnesium toxicity. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.

A client is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this client? a. oxytocin therapy b. fluid replacement c. pain management d. increasing activity

a. oxytocin therapy With a prolonged descent, intravenous oxytocin may be used to induce the uterus to contract effectively. Fluid replacement, pain management, and activity will not cause the fetus to descend quicker.

A 34-year-old female client with a chronic pelvic infection expresses a desire to conceive posttreatment. The client asks the nurse, "Do you see any problems that I may have since I keep having this issue?" Which nursing response is appropriate? a. "Chronic infection may lead to scarring or narrowing of the fallopian tubes." b. "Once the infection is cleared, there is no further concern with conception." c. "I am unsure of any change in the reproductive tract that may cause issues." d. "Stretching of the reproductive tract due to swelling is a cause of multiple births."

a. "Chronic infection may lead to scarring or narrowing of the fallopian tubes." The woman is asking for specific guidance from the nurse regarding possible issues due to chronic pelvic infections. The nurse is most correct to answer by stating that chronic pelvic infection increases the risk for narrowed or blocked fallopian tubes. It decreases the possibility of fertility or increases the risk of ectopic pregnancy. Stating that the nurse is unsure and providing a broad statement with no real facts to support is not therapeutic. Chronic infections will narrow (not stretch) the reproductive tract. Chronic infections cause reproductive concerns even after the infection is cleared.

The nurse is teaching an antepartum class to first-time mothers. A mother asks the nurse if she should stay in bed when her contractions start. How should the nurse respond? a. "No, walking actually shortens the first stage of labor." b. "No, but you need to only walk for 15-minute intervals." c. "Yes, you don't want to risk having your water break while you are walking." d. "Yes, it is important so monitoring can be done for you and the baby."

a. "No, walking actually shortens the first stage of labor." Maternal position can affect the progress of labor. An upright instead of a horizontal position may shorten the first stage of labor as much as 90 minutes, especially if a mother has given birth before. An upright position also shortens the second stage of labor, reduces the rate of surgical vaginal deliveries, and helps reduce labor pain. An upright position includes sitting, kneeling, squatting and standing. The mother has options other than just sitting in a chair. Staying in bed to reduce the risk of membranes rupturing is not valid. Monitoring can be done while the mother is upright.

A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best? a. "Please come in now for an evaluation by your health care provider." b. "Lie on your left side and drink lots of water and monitor the bleeding." c. "If the bleeding lasts more than 24 hours, call us for an appointment." d. "Bleeding during pregnancy happens for many reasons, some serious and some harmless."

a. "Please come in now for an evaluation by your health care provider." Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.

While the placenta is being delivered after labor, a client experiences an amniotic fluid embolism. What should the nurse do first to help this client? a. Administer oxygen by nasal cannula. b. Increase intravenous fluid infusion rate. c. Put firm pressure on the fundus of the uterus. d. Tell the client to take short, shallow breaths.

a. Administer oxygen by nasal cannula. The clinical picture of an amniotic fluid embolism is dramatic. The client suddenly experiences sharp chest pain and is unable to breathe as pulmonary artery constriction occurs. The immediate management is oxygen administration by face mask or cannula. Intravenous fluids; pressure on the fundus; or taking short, shallow breaths is not going to help the manifestations of an amniotic fluid embolism.

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best? a. "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." b. "I know that it is sad but the pregnancy must be terminated to save your life." c. "The choice is up to you but the health care provider is recommending an induced abortion (medical abortion). d. "You have experienced an incomplete abortion (miscarriage) and must have the placenta and any other tissues cleaned out."

a. "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth? a. 11 b. 7 c. 5 d. 3

a. 11 The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Therefore the woman with a Bishop score of 11 would have the greatest chance for success. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.

A nurse is caring for a client with cardiovascular disease who has just given birth. What nursing interventions should the nurse perform when caring for this client? Select all that apply. a. Assess for shortness of breath. b. Assess for a moist cough. c. Assess for edema and note any pitting. d. Auscultate heart sounds for abnormalities. e. Monitor the client's hemoglobin and hematocrit.

a. Assess for shortness of breath. b. Assess for a moist cough. c. Assess for edema and note any pitting. d. Auscultate heart sounds for abnormalities. The nurse should assess for possible fluid overload in a client with cardiovascular disease who has just given birth. Signs of fluid overload in the client who has just labored include cough, progressive dyspnea, edema, palpitations, and crackles in the lung bases. Hemoglobin and hematocrit levels are not affected by laboring of the client with cardiovascular disease.

The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to titrating the infusion upward for adequate contractions? a. Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min. b. After one hour, titrate the infusion upward by 1 to 2 mu/min until contractions are adequate. c. Start oxytocin drip, piggyback to main IV line to port closest to client. d. Discontinue infusion if contractions are every 2 minutes lasting 60 to 90 seconds each.

a. Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min. Hyperstimulation is usually defined as five or more contractions in a 10-minute period or contractions lasting more than 2 minutes in duration or occurring within 60 seconds of each other. The surest method to relieve hyperstimulation is to immediately discontinue the oxytocin infusion. The rate should not be increased by more than 2 milliunits at a time. When the infusion is administered, the oxytocin solution should be "piggybacked" to a maintenance IV solution such as Ringer's lactate and the piggyback added to the main infusion at the port closest to the woman. Infusions are usually begun at a rate of 1 to 2 milliunits/min. If there is no response, the infusion is gradually increased every 30 to 60 minutes by small increments of 1 to 2 milliunits/min until contractions begin.

A pregnant client late in the second trimester comes to the emergency department with a report of painless, bright red vaginal bleeding. The client states, "It started all of a sudden and now it seems to have stopped." Placenta previa is suspected. Which action should the nurse implement immediately for this client? a. Determine fetal heart sounds using an external monitor. b. Prepare the client for an immediate cesarean birth. c. Assist with insertion of internal monitoring to assess uterine pressure. d. Prepare the client for a pelvic examination to assess rupture of membranes.

a. Determine fetal heart sounds using an external monitor. For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal monitoring is contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both the pregnant client and fetus. The decision to birth the fetus depends on the point at which a diagnosis of placenta previa is made and the age of the gestation. If labor has begun, bleeding is continuing, or the fetus is being compromised (measured by the response of the fetal heart rate to contractions), birth must be accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, pregnant client vital signs are good, and the fetus is not yet 36 weeks of age, a client is usually managed by expectant watching.

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? a. Keeping the communication lines open. b. Leaving the parents alone. c. Removing the infant quickly. d. Contacting a grief counselor.

a. Keeping the communication lines open. Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye.

The mother comes to her prenatal appointment. She tells the nurse that it feels like the baby is kicking on her bladder and it is harder to breathe. The nurse suspects the fetus is in breech position. Which procedure would the nurse implement to determine the position of the baby? a. Leopold maneuvers b. McRoberts maneuver c. Rubin maneuver d. Gaskin maneuver

a. Leopold maneuvers Diagnosis of breech presentation is usually by Leopold maneuvers. These maneuvers are done by palpating the maternal abdomen to feel the location of the fetal parts (head, back, buttocks, etc.). A sign of breech presentation is the mother's report of pressure from the fetal head against the fundus and kicking in the lower abdomen. McRoberts, Rubin, and Gaskin maneuvers are all procedures used in the delivery room when shoulder dystocia is present.

A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority? a. avoidance of infection b. constipation prevention c. administration of immunoglobulins d. consumption of a low-fat diet

a. avoidance of infection Prevention of crises, if possible, is the focus of treatment for the pregnant woman with sickle cell anemia. Maintaining adequate hydration, avoiding infection, getting adequate rest, and eating a balanced diet are all common-sense strategies that decrease the risk of a crisis. Fat intake does not need to be decreased and immunoglobulins are not normally administered. Constipation is not usually a result of sickle cell anemia.

A pregnant woman with a history of mitral valve stenosis is to be prescribed medication as treatment. Which medication class would the nurse expect the client to be prescribed? a. anticoagulant b. vasodilator c. inotropic d. angiotensin receptor blockers

a. anticoagulant In mitral valve stenosis, it is difficult for blood to leave the left atrium. A secondary problem of thrombus formation may develop as a result of noncirculating blood. A woman may need to be prescribed an anticoagulant to prevent this complication. Vasodilators are used for peripartum cardiomyopathy. Inotropics are used for heart failure. Angiotensin receptor blockers are used for congestive heart failure.

A client with systemic lupus erythematosus (SLE) is receiving postpartum care after the birth process. Which medication does the nurse anticipate being prescribed for this client? a. aspirin b. diuretic c. beta blocker d. glucocorticoid

a. aspirin Because of the high risk for preeclampsia in a client with systemic lupus erythematosus (SLE), low-dose aspirin therapy (81 mg daily) is recommended starting between 12 and 20 weeks' postpartum. Diuretics and beta blockers are not routinely prescribed for pregnant clients with SLE. Glucocorticoids would be used to treat fetal heart block.

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? a. cesarean birth b. administration of oxytocin c. administration of morphine sulfate d. darkening room lights and decreasing noise and stimulation

a. cesarean birth If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.

A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition? a. cytomegalovirus b. chlamydia c. gonorrhea d. toxoplasmosis

a. cytomegalovirus The nurse would be alert for the development of cytomegalovirus infection. Pregnant women acquire active disease primarily from sexual contact, blood transfusions, kissing, and contact with children in day care centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breastfeeding. Chlamydia, gonorrhea, and toxoplasmosis are not spread through contact with children in day care centers.

A woman who is 42 weeks' pregnant comes to the clinic. During the visit, which assessment should the nurse prioritize? a. determining an accurate gestational age b. asking her about the occurrence of contractions c. checking for spontaneous rupture of membranes d. measuring the height of the fundus

a. determining an accurate gestational age Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client? a. diet b. long-acting insulin c. oral hypoglycemic drugs d. glucagon

a. diet Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are usually not given during pregnancy and would not be the first option. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.

The nurse reviews the note for a client who is 16 weeks' pregnant (above). For which potential condition will the nurse assess this client? a. eating disorder b. substance use disorder c. intimate partner violence (IPV) d. phenylketonuria (PKU) of the pregnant parent

a. eating disorder The client is demonstrating warning signs of an eating disorder such as a low body mass index (BMI), lack of weight gain over prenatal visits, anxiety or a mood disorder, and hyperemesis gravidarum. The client's assessment findings are not associated with substance use disorder, intimate partner violence (IPV), or phenylketonuria (PKU) of the pregnant parent.

A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP? a. elevated lipoproteins b. hemolysis c. liver enzyme elevation d. low platelet count

a. elevated lipoproteins The acronym HELLP represents hemolysis, elevated liver enzymes, and low platelets. This syndrome is a variant of preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.

It is necessary for the mother to have a forceps delivery. To reduce complications from this procedure, the nurse should: a. empty the mother's bladder. b. provide pain medication. c. have anesthesia provider present. d. call the neonatologist.

a. empty the mother's bladder. Forceps delivery may be outlet, low, or midforceps depending on the station of the fetus and the rotation of the fetal head. Client consent must be obtained and the maternal bladder must be emptied to reduce the chance of bladder injury and to increase the room for the fetus. The anesthesia provider and neonatologist would only be necessary if there was suspicion of complications to the mother and the fetus.

A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? a. external cephalic version b. trial labor c. forceps birth d. vacuum extraction

a. external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilation (dilatation) of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize? a. fetal heart tones b. signs of shock c. infection d. uterine stabilization

a. fetal heart tones When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect? a. firm, rigid uterus on palpation b. gradual onset of symptoms c. fetal heart rate within normal range d. absence of pain

a. firm, rigid uterus on palpation The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? a. grade 2 b. grade 1 c. grade 3 d. grade 4

a. grade 2 The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.

A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? a. grade 2 b. grade 1 c. grade 3 d. grade 4

a. grade 2 The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.

A primigravida at 28 weeks' gestation comes to the clinic for a checkup. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply. a. history of previous preterm birth b. current multiple gestation pregnancy c. large-for-gestational-age fetus d. uterine or cervical abnormalities e. previous cesarean birth

a. history of previous preterm birth b. current multiple gestation pregnancy d. uterine or cervical abnormalities The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.

A client is admitted with a diagnosis of ruptured ectopic pregnancy. For what should the nurse anticipate preparing the client? a. immediate surgery b. internal uterine monitoring c. bed rest for the next 4 weeks d. intravenous administration of a tocolytic

a. immediate surgery An ectopic pregnancy is one in which implantation occurred outside the uterine cavity, usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The client does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the client is not in labor.

The nurse reviews the medication therapy regimen of a pregnant woman with chronic hypertension. Which medication would the nurse most likely expect to find? a. labetalol b. atenolol c. carvedilol d. metoprolol

a. labetalol Although beta-blockers and calcium channel blockers may be prescribed to reduce blood pressure by peripheral dilation to a safe level, it should not be reduced below the threshold that allows for good placenta circulation. Labetalol and nifedipine are typical drugs that may be prescribed.

Four hours after giving birth a mother suddenly complains of not being able to breathe and is gasping for breath. The nurse administers oxygen and calls for help. Which type of oxygen delivery device would be most appropriate for the nurse to utilize? a. nonrebreather mask b. Venturi mask c. face mask d. nasal cannula

a. nonrebreather mask An amniotic fluid embolism occurs when amniotic fluid enters the maternal circulation. It is always an emergency. Providing oxygenation is crucial to prevent respiratory failure. The goal is to keep the PaO2 level above 65 mm Hg. This can be accomplished with a nonrebreather mask at a rate of 8-10L/min or by a resuscitation bag delivering 100% oxygen. The other options are incorrect because they will not provide enough flow rate or FiO2.

The nurse is caring for a woman at 32 weeks' gestation who expresses deep concern because her previous pregnancy ended in a stillbirth. The nurse would encourage the mother to have what screening test? a. nonstress test (NST) b. contraction stress test c. vaginal ultrasound d. doppler ultrasound

a. nonstress test (NST) Women with a history of previous stillbirth begin antepartum fetal testing 1 to 2 weeks prior to the gestational age at which the intrauterine demise occurred, or no later than 32 to 34 weeks' gestation. One method to assess the well-being of the fetus is the biophysical profile. Included in this is the nonstress test. Other regular screening methods are having the mother keep a record of kicks (fetal movement counts/kick counts) and monitoring for hypertensive disorders and diabetes. An abdominal ultrasound could screen for fetal growth restriction. A Doppler ultrasound measures the blood flow of the fetus but it is not part of the regular screening unless fetal problems have been identified.

A woman with an artificial mitral valve develops heart failure at the 20th week of pregnancy. Which measure would the nurse stress with her during the remainder of the pregnancy? a. obtaining enough rest b. maintaining a high fluid intake c. beginning a low-impact aerobics program d. discontinuing her prepregnancy anticoagulant

a. obtaining enough rest As the blood volume doubles during pregnancy, heart failure can occur. The pregnant woman needs to obtain adequate rest to prevent overworking the heart. Fluid may need to be restricted.

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring? a. preterm labor b. normal labor c. dystocia d. precipitate labor

a. preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation (dilatation) before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from the start of contraction to birth.

A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client? a. preterm rupture of membranes followed by preterm birth b. development of eclampsia c. hemorrhaging d. development of gestational trophoblastic disease

a. preterm rupture of membranes followed by preterm birth Even with precautions, in most instances of polyhydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.

A client at 37.6 weeks' gestation is admitted to labor and delivery with ruptured membranes for 24 hours and uterine contractions every 3 to 4 minutes. The client has a temperature of 100.8°F (38.22°C) and a heart rate of 114 beats/min. The fetal heart rate is 170 beats/min. Based on this information, for which potential complication(s) will the nurse monitor? Select all that apply. a. prolonged labor b. postpartum venous thrombus c. neonatal intraventricular hemorrhage d. shoulder dystocia e. fetal dysmaturity

a. prolonged labor b. postpartum venous thrombus c. neonatal intraventricular hemorrhage Based on the information provided, this client is displaying signs of chorioamnionitis. Client complications of chorioamnionitis include prolonged labor and a risk for postpartum venous thrombus; neonatal complications include risk for intraventricular hemorrhage. Shoulder dystocia and fetal dysmaturity are associated with a postterm pregnancy, not chorioamnionitis.

A woman has presented to the emergency department with symptoms that suggest an ectopic pregnancy. Which finding would lead the nurse to suspect that the fallopian tube has ruptured? a. referred shoulder pain b. vaginal spotting c. nausea d. breast tenderness

a. referred shoulder pain Referred pain to the shoulder area indicates bleeding into the abdomen caused by phrenic nerve irritation when a tubal pregnancy ruptures. Vaginal spotting, nausea, and breast tenderness are typical findings of early pregnancy and an unruptured ectopic pregnancy.

A nurse is providing care to a pregnant client newly diagnosed with human chorionic gonadotropin (hCG)-mediated hyperthyroidism. The nurse is preparing educational materials on an appropriate treatment option for the client. On which treatment will the nurse provide information to the client? a. serial T4 and thyroid-stimulating hormone (TSH) assessments b. thyroidectomy c. initiation of thioamide therapy d. a course of beta blockers

a. serial T4 and thyroid-stimulating hormone (TSH) assessments The nurse provides information on serial T4 and thyroid-stimulating hormone (TSH) assessments that will occur over a 6-week period. Some providers choose this option instead of treatment for some subclinical and mild forms of hyperthyroidism, including human chorionic gonadotropin (hCG)-mediated hyperthyroidism. A thyroidectomy is an option for clients who cannot take or tolerate medications for hyperthyroidism. Thioamides are medications that include methimazole and propylthiouracil (PTU) and are used to suppress thyroid hormone synthesis, and beta blockers are medications sometimes used short term in clients who are symptomatic until the thiomide becomes effective.

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)? a. strong abdominal cramping b. slight vaginal bleeding c. closed cervical os d. no passage of fetal tissue

a. strong abdominal cramping Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.

A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth? a. the viral load b. amniocentesis results at 34 weeks' gestation c. the mother's age d. prophylactic antiretroviral therapy (ART) to the infant at birth

a. the viral load A woman who has HIV during pregnancy is at risk for transmitting the infection to the fetus during pregnancy or childbirth and to the newborn while breastfeeding. The type of birth, vaginal or cesarean, depends on several factors, including the woman's viral load, use of ART during pregnancy (not waiting until the birth), length of time membranes have been ruptured, and gestational age (not mother's age). With prenatal ART and prophylactic treatment of the newborn, there is a reduced risk of perinatal HIV transmission. The amniocentesis results would not be a factor in preventing the spread of HIV to the infant and may actually lead to the fetus being infected through the puncture site and bleeding into the amniotic sac.

A client with a body mass index (BMI) of 32 states their last menstrual period was "about 3 months" ago. Which method will the nurse anticipate being used initially to help determine the week of gestation? a. ultrasound b. fundal height c. fetal heartbeat d. fetal echocardiogram

a. ultrasound It can be challenging to determine fetal age in the client who is a poor historian and has a BMI between 30 and 39.9. Early in pregnancy, an ultrasound may be ordered to accurately date the week of gestation. When a pregnant client is categorized as obese, fundal height measurements can be less accurate. Assessing the fetal heartbeat will not help determine the week of gestation. If the fetal ultrasound is inconclusive, a fetal echocardiogram may be prescribed.

A nurse is caring for a pregnant client admitted with mild preeclampsia. Which assessment finding should the nurse prioritize? a. urine output of less than 15 ml/hr b. 1+ ankle edema c. mild hand edema d. proteinuria of 200 mg/24 hours

a. urine output of less than 15 ml/hr Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 500 mg in 24 hours, oliguria of less than 15 ml/hr, cerebral and visual symptoms, and rapid weight gain. Mild facial edema or hand edema occurs with mild preeclampsia. A urinary output of 15 ml/hr would result in an output of 360 ml/24 hours, which would be below the recommended range and should be reported. Ankle edema of 1+ could be related to regular pregnancy and not necessarily just severe preeclampsia. A finding of 3+ to 4+ pitting edema would be more alarming and require intervention.

The nurse is evaluating care provided to a client in the third trimester of pregnancy who has been diagnosed with gestational hypertension. Which finding indicates that treatment has been successful for this client? a. urine protein 0 b. increased perspiration c. weight gain of 1 lb/week d. diastolic blood pressure 20 mmHg over normal level

a. urine protein 0 Manifestations of gestational hypertension include elevated blood pressure, edema, and proteinuria. Absence of protein in the urine indicates that treatment has been successful. Increased perspiration is not a manifestation of gestational hypertension. A weight gain of 1 lb/week in the client who is in the third trimester of pregnancy is an indication of ongoing edema. A diastolic blood pressure that is 20 mmHg over normal level is an indication of ongoing hypertension.

The obstetric nurse is caring for a pregnant client who has been diagnosed with a hydatidiform mole. What assessment should the nurse prioritize? a. vaginal bleeding b. blood pressure c. pain d. severe nausea and vomiting

a. vaginal bleeding Molar pregnancies constitute a major risk factor for vaginal bleeding. The client does not normally have an increased risk for nausea, pain, or hypertension.

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? a. "I will make handprints and footprints of the baby for you to keep." b. "I know you are hurting, but you can have another baby in the future." c. "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" d. "Have you named your baby yet? I would like to know your baby's name."

b. "I know you are hurting, but you can have another baby in the future." Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? a. well coordinated. b. poor in quality. c. brief. d. erratic.

d. erratic. Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.

The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or during the birth for the infant. Which statement by the mother indicates that further teaching is needed by the nurse? a. "My baby may be very large and I may need a cesarean birth to have him." b. "If my blood sugars are elevated, my baby's lungs will mature faster, which is good." c. "Beginning at 28 weeks' gestation, I will start counting with my baby's movements every day." d. "I may need an amniocentesis during the third trimester to see if my baby's lungs are ready to be born."

b. "If my blood sugars are elevated, my baby's lungs will mature faster, which is good." Elevated blood sugars delay the maturation of fetal lungs, not increase maturation time, resulting in potential respiratory distress in newborns born to mothers with diabetes. Doing fetal movement (kick) counts is standard practice, as is the possibility of an amniocentesis to determine lung maturity during the third trimester. Health care personnel should also prepare the mother for the potential of a cesarean birth if the infant is too large.

A client with systemic lupus erythema (SLE) wants to have a baby. Which response will the nurse make after learning the client had an exacerbation of SLE 3 months ago? a. "Now would be a good time for you to become pregnant." b. "It is best to wait until you have not had an exacerbation for 6 months." c. "Blood tests to monitor liver and kidney function are not needed while pregnant." d. "The medications that you are taking should be stopped if trying to become pregnant."

b. "It is best to wait until you have not had an exacerbation for 6 months." Systemic lupus erythematosus (SLE) is an autoimmune disease in which the immune system attacks various parts of the body. This condition poses a risk for both the client and fetus in pregnancy and it is safest to attempt pregnancy when the disease has been in remission for at least 6 months. Clients who have had active disease within the last 6 months prior to pregnancy are most likely to experience disease exacerbation while pregnant. For the client with SLE, laboratory tests to examine kidney and liver function should be done prior to becoming pregnant and periodically during the pregnancy. Some medications used to treat SLE are contraindicated and others may be considered safe but with reduced dosing. The client should not stop taking any medications.

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate? a. "If you do not get up to walk you will not recover." b. "Walking is the best way to prevent complications such as blood clots." c. "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." d. "Maybe you will feel better after you take pain medication."

b. "Walking is the best way to prevent complications such as blood clots." The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education.

Although many women envision a plan of how labor will go, sometimes complications happen, and their plan is no longer achievable. When this happens, what is the best question the nurse can ask the woman at this time? a. "Do you think your baby knows how you wanted your labor to progress?" b. "What do you consider your primary goal for the outcome of this pregnancy?" c. "Have you ever had your plans changed in the middle of the project?" d. "How do you handle events that do go your way?"

b. "What do you consider your primary goal for the outcome of this pregnancy?" If a complication of labor or birth occurs, identification of expected outcomes can be difficult because an outcome that must be included in planning may not be what the woman desires. Encouraging a couple to clarify their priorities when a complication occurs is helpful. Asking "if the baby knows" is trying to provoke humor and is inappropriate at this time. Asking if plans have ever changed in the middle of a project does not focus on the ultimate goal of delivering a healthy baby. Trying to find out how a client deals with unanticipated changes does not focus on the priority of a healthy baby.

A young adult client with anorexia nervosa is concerned about missing menstrual periods for several months. How will the nurse respond? a. "It is unlikely that you are pregnant." b. "You may still ovulate and can be pregnant." c. "Being pregnant will help cure the eating disorder." d. "Spontaneous abortions are common with your condition."

b. "You may still ovulate and can be pregnant." A client with anorexia nervosa may not menstruate or may menstruate irregularly. The nurse should inform clients with eating disorders who do not menstruate regularly that a lack of menses does not necessarily indicate a lack of ovulation and that they may still be fertile. The nurse has no way of knowing if the client is pregnant. Pregnancy does not "cure" an eating disorder, because these clients may experience depression and distress caused by the change in body weight associated with a pregnancy. There is no evidence that clients with anorexia nervosa experience spontaneous abortions.

A client presents to the prenatal clinic for a first trimester visit. The client has a history of Class A pregestational diabetes. The client asks the nurse how the disease will be managed during their pregnancy. How will the nurse respond? a. "You are on insulin now, so you will continue with that treatment regimen." b. "Your diabetes will be managed based on your glucose levels." c. "Because you have diabetes, you will need to give birth early." d. "Testing for fetal well-being will begin during your first trimester."

b. "Your diabetes will be managed based on your glucose levels." The nurse will inform the client that their diabetes will be managed based on glucose levels during pregnancy. The client has Class A diabetes, meaning the disease is managed with diet alone and is not insulin-dependent. Not all pregnant clients with diabetes give birth early. That may be an option in the presence of poor glycemic control and/or in fetal compromise. Antepartum testing for fetal well-being, such as nonstress tests, contraction stress tests, and biophysical profiles, are performed beginning between 32 and 34 weeks' gestation or the third trimester; this client is in the first trimester.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result? a. 3.3 mEq/L b. 6.1 mEq/L c. 8.4 mEq/L d. 10.8 mEq/L

b. 6.1 mEq/L Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? a. Explain to her that there was probably something wrong with the infant and that is why it died. b. Offer to take pictures and footprints of the infant once it is delivered. c. Call the hospital chaplain to talk to the parents. d. Recommend that she not hold the infant after it is delivered so as to not upset her more.

b. Offer to take pictures and footprints of the infant once it is delivered. When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parent's approval.

A pregnant client at 32 weeks' gestation is treated with magnesium sulfate for seizure management. The nurse assesses which of the following for evidence of magnesium toxicity? a. frequency of micturition b. absence of knee jerk response c. increased blood pressure d. increased rate of respiration

b. absence of knee jerk response Magnesium sulfate toxicity is characterized by an absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, not frequency of micturition, is seen with magnesium sulfate toxicity. Magnesium sulfate is given to treat seizures associated with hypertension and proteinuria in pregnancy, and therefore decreases the blood pressure. It does not cause an increase in blood pressure. There is respiratory depression, and not an increased rate of respiration, with magnesium sulfate toxicity.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? a. breast stimulation b. amniotomy c. laminaria d. prostaglandin

b. amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? a. cord compression b. fetal distress related to hypoxia c. infection d. central nervous system (CNS) involvement

b. fetal distress related to hypoxia When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

Which assessment finding will alert the nurse to be on the lookout for possible placental abruption (abruptio placentae) during labor? a. macrosomia b. gestational hypertension c. gestational diabetes d. low parity

b. gestational hypertension Risk factors for placental abruption (abruptioo placentae) include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, intimate partner violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.

A nurse is describing the risks associated with post-term pregnancies as part of an in-service presentation. The nurse determines that more teaching is needed when the group identifies which factor as an underlying reason for problems concerning the fetus? a. aging of the placenta b. increased amniotic fluid volume c. meconium aspiration d. cord compression

b. increased amniotic fluid volume Fetal risks associated with a post-term pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline after 38 weeks' gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult (Norwitz, 2019). All of these issues can compromise fetal well-being and lead to fetal distress.

A client at 30 weeks' gestation is admitted to labor and delivery with a diagnosis of a class 2 acute placental abruption. Which intervention(s) will the nurse plan to implement when providing care for the client? Select all that apply. a. intermittent fetal monitoring b. inserting large-bore intravenous (IV) access c. monitoring client's intake and output d. administering corticosteroids e. administering magnesium sulfate

b. inserting large-bore intravenous (IV) access c. monitoring client's intake and output d. administering corticosteroids The nurse plans to insert a large-bore IV, monitor client intake and output, and administer corticosteroids. An acute class 2 placental abruption presents with mild to moderate abdominal tenderness, uterine contractions, signs of hemodynamic instability, and fetal distress, which can necessitate a preterm birth. The nurse should utilize continuous, not intermittent, fetal monitoring. Tocolysis is contraindicated with a placental abruption.

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition? a. hemorrhage b. macrosomia c. infection d. dystocia

b. macrosomia Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks' gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia pose a risk to the mother, not the fetus.

A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority? a. fluid replacement b. oxygenation c. control of hypertension d. birth of the fetus

b. oxygenation As with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable.

A client who is 18 weeks' pregnant has a history of depression. For which potential effect should the nurse plan care for this client? a. fetal demise b. preterm birth c. large for gestational age d. placental abruption

b. preterm birth Preexisting depression and antepartum depression are associated with a small increased risk for preterm birth. Fetal demise, large for gestational age, and placental abruption are not associated with preexisting or antepartum depression.

A nurse has been assigned to four antepartum clients. Which client requires immediate follow-up by the nurse? a. the client with type 1 diabetes whose nonstress test is nonreactive b. the client with a cardiomyopathy whose respiratory rate is 32 breaths/min c. the client with sickle cell anemia whose hemoglobin level is 9.8 g/dl (98 g/l) d. the client with chronic hypertension whose blood pressure is 146/90 mm Hg

b. the client with a cardiomyopathy whose respiratory rate is 32 breaths/min The nurse first assesses the client with the cardiomyopathy whose respirations are 32 breaths/min. A respiratory rate greater than 25 breaths/min is a sign of cardiac decompensation and requires prompt follow-up. A nonreactive nonstress test can be due to a variety of reasons, including medications being taken by the antepartum client and fetal sleep patterns; it requires a continuation of the test for at least 40 minutes or as long as 120 minutes but does not require an immediate follow-up. A client with sickle cell anemia who has hemoglobin of 9.8 g/dl (98 g/l) is considered acceptable. A client with chronic hypertension and a blood pressure of 146/90 mm Hg is considered to have mild disease when untreated or has achieved goals if treated for severe disease.

A nurse is performing an assessment on a new client. The woman estimates that she is approximately 16 weeks pregnant. While assessing her, the nurse asks her about apparent scratch marks on her hands, and she tells the nurse that she has three cats at home. What screening would be prescribed for this woman? a. cytomegalovirus b. toxoplasmosis c. hepatitis C d. herpes simplex virus

b. toxoplasmosis Toxoplasmosis is an infection caused by the protozoan Toxoplasma gondii, also referred to as T. gondii. Transmission is via undercooked meat and through cat feces. Toxoplasmosis is a common infection in humans and usually produces no symptoms. However, when the infection passes from the woman through the placenta to the fetus, a condition called congenital toxoplasmosis can occur. Approximately 400 to 4,000 cases of congenital toxoplasmosis occur per year in the United States (Williams, 2007). The classic triad of symptoms for congenital toxoplasmosis is chorioretinitis, intracranial calcification, and hydrocephalus in the newborn.

A pregnant woman at the emergency department informs staff that she is at least 2 weeks past her due date. The physician begins to perform several tests to determine fetal age. The nurse anticipates that the woman's amniotic fluid volume will be decreased. How would the nurse measure the amniotic fluid in this situation? a. x-ray b. ultrasound c. aspiration d. palpation

b. ultrasound When a client presents with an intrauterine pregnancy at or past 42 weeks, the team will attempt to determine fetal age using different methods. Decreased amniotic fluid may be present and can be measured by ultrasound. The other methods cannot determine volume of amniotic fluid.

A nursing instructor is teaching students about preexisting illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement? a. "A pregnant woman with a chronic condition can put herself at risk." b. "A pregnant woman with a chronic illness can put the fetus at risk." c. "A pregnant woman does not have to worry about contracting new illnesses during pregnancy." d. "A pregnant woman needs to be careful of and cautious about accidents and illnesses during her pregnancy."

c. "A pregnant woman does not have to worry about contracting new illnesses during pregnancy." When a woman enters a pregnancy with a chronic illness, it can put both her and the fetus at risk. She needs to be cautious about developing a new illness during her pregnancy as well as having an accident during the pregnancy.

The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems? a. "Increase your fluid intake to prevent dehydration." b. "Be sure to measure 24-hour urine output daily." c. "Continue to monitor fetal movements daily." d. "Monitor your bowel movements for constipation."

c. "Continue to monitor fetal movements daily." The nurse will teach the postterm client to monitor fetal movements (kick counts) daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.

A mother is talking to the nurse and is concerned about managing her asthma while she is pregnant. Which response to the nurse's teaching indicates that the woman needs further instruction? a. "I need to be aware of my triggers and avoid them as much as possible." b. "It is fine for me to use my albuterol inhaler if I begin to feel tight." c. "I need to begin taking allergy shots like my friend to prevent me from having an allergic reaction this spring." d. "I will monitor my peak expiratory flow rate regularly to help me predict when an asthma attack is coming on."

c. "I need to begin taking allergy shots like my friend to prevent me from having an allergic reaction this spring." A pregnant woman with a history of asthma needs to be proactive, taking her inhalers and other asthma medications to prevent an acute asthma attack. She needs to understand that it is far more dangerous to not take the medications and have an asthma attack. She also needs to monitor her peak flow for decreases, be aware of triggers, and avoid them if possible. However, a pregnant woman should never begin allergy shots if she has not been taking them previously, due to the potential of an adverse reaction.

A nurse is teaching a pregnant woman with preterm premature rupture of membranes (PPROM) about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching? a. "I need to keep a close eye on how active my baby is each day." b. "I need to call my doctor if my temperature increases." c. "It's okay for my husband and I to have sexual intercourse." d. "I can shower, but I shouldn't take a tub bath."

c. "It's okay for my husband and I to have sexual intercourse." The woman with preterm PROM should monitor her baby's activity by performing fetal movement (kick) counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, (such as tampons or having vaginal intercourse), and avoid sitting in a tub bath.

The nurse is teaching a pregnant client with type 2 diabetes about diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? a. "I'll basically follow the same diet that I was following before I became pregnant." b. "Because I need extra protein, I will have to increase my intake of milk and meat." c. "Pregnancy affects insulin production, so I will need to make adjustments in my diet." d. "I will adjust my diet and insulin based on the results of my urine tests for glucose."

c. "Pregnancy affects insulin production, so I will need to make adjustments in my diet." In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the client will probably need to make adjustments in the diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.

A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective? a. "Staples are put in the cervix to prevent it from dilating." b. "The cervix is glued shut so no amniotic fluid can escape." c. "Purse-string sutures are placed in the cervix to prevent it from dilating." d. "A cervical cap is placed so no amniotic fluid can escape."

c. "Purse-string sutures are placed in the cervix to prevent it from dilating." The cerclage, or purse string suture, is inserted into the cervix to prevent preterm cervical dilation (dilatation) and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.

The nurse is caring for a client with sickle cell disease who is in the 24th week of pregnancy. Which response will the nurse make when the client asks why weekly examinations are needed for the remainder of the pregnancy? a. "Your baby is at risk for having sickle cell disease." b. "You are at risk for bleeding and need to be monitored." c. "Your risk of having a crisis increases as the pregnancy progresses." d. "Your baby is growing too large and you might need to give birth sooner."

c. "Your risk of having a crisis increases as the pregnancy progresses." Sickle cell anemia is categorized as either sickle cell trait or sickle cell disease. Sickle cell disease affects almost all organ systems of the body. Because approximately half of pregnant clients with sickle cell disease experience a crisis related to pregnancy, usually in the last months of pregnancy, an increase in examinations would be warranted. The fetus's risk of having sickle cell disease will depend on the results of preconception genetic counseling. Clients with sickle cell disease have a lower risk of postpartum hemorrhage. Obstetrical risks for a client with sickle cell disease include fetal growth restriction, not a fetus that is large for gestational age.

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test? a. 8% b. 14% c. 6% d. 12%

c. 6% The upper normal level of HbA1C is 6% of total hemoglobin.

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? a. If the woman has a full bladder, labor may be uncomfortable for her. b. If the woman's bladder is distended, it may rupture. c. A full bladder or rectum can impede fetal descent. d. A full rectum can cause diarrhea.

c. A full bladder or rectum can impede fetal descent. Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.

A pregnant client with sickle cell anemia is admitted in crisis. Which nursing intervention should the nurse prioritize? a. antihypertensive drugs b. diuretic drugs c. IV fluids d. antibiotics

c. IV fluids A sickle cell crisis during pregnancy is usually managed by exchange transfusion, oxygen, and IV fluids. Antihypertensive drugs usually aren't necessary. Diuretics would not be used unless fluid overload resulted. The client would be given antibiotics only if there were evidence of an infection.

A client who has cardiac disease and is at 36 weeks' gestation presents for a scheduled prenatal visit. The nurse has completed an assessment (above). Which is the appropriate action for the nurse to take? a. Explain that the swelling and increased fatigue are normal findings during pregnancy. b. Document the assessment as normal findings during late pregnancy. c. Notify the health care provider of the findings for further assessment. d. Extend the nonstress test for an additional 40 minutes.

c. Notify the health care provider of the findings for further assessment. The nurse will notify the health care provider of the findings, because the client's swelling, palpitations, increased fatigue, cough, and vital signs are suggestive of cardiac decompensation. Fatigue and swelling of the fingers and lower extremities are normal findings in late pregnancy but coupled with the heart rate, respirations, cough, and palpitations are abnormal findings. A reactive nonstress test is a normal finding that does not require extending the test.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? a. Check deep tendon reflexes. b. Measure fundal height. c. Palpate the fundus and check fetal heart rate. d. Obtain a voided urine specimen and determine blood type.

c. Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.

The nurse is monitoring a pregnant client who is receiving intravenous magnesium sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What should the nurse do? a. Check the fetal heart rate. b. Measure blood pressure. c. Stop the current infusion. d. Increase the infusion rate.

c. Stop the current infusion. When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes are absent. Checking the fetal heart rate and measuring blood pressure could waste time and provide the client with more magnesium sulfate. The infusion rate should not be increased because this could lead to cardiac dysrhythmias and respiratory depression.

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate? a. Slow the oxytocin infusion to the initial rate. b. Continue to monitor contractions and fetal heart rate. c. Stop the infusion immediately. d. Notify the birth attendant.

c. Stop the infusion immediately. The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.

A physician has prescribed magnesium sulfate for a client with premature labor. Data collection reveals the client's respiratory rate is 12 breaths/minute, and urine output is 30 ml/hour. The magnesium sulfate serum levels are 7 mg/dl. When questioned, the client reports feeling warm and flushed. Based upon the nurse's understanding of magnesium sulfate, what action is most appropriate? a. The client is demonstrating early signs of toxicity and the dosage should be reduced. b. The client is demonstrating an allergic reaction and the medication should be discontinued immediately. c. The client's response is appropriate and within normal limits; therefore, no action is necessary. d. The client is demonstrating potential complications and the physician should be notified.

c. The client's response is appropriate and within normal limits; therefore, no action is necessary. Magnesium sulfate is associated with feelings of warmth and flushing; these symptoms do not indicate toxicity or allergic reaction. Respirations of 12 breaths/minute are considered normal. Urine output should be at least 30 ml/hour. Serum levels of magnesium sulfate should be between 4 and 8 mg/dl to promote a therapeutic response.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding? a. urinary output of 20 mL per hour b. respiratory rate of 10 breaths/minute c. deep tendons reflexes 2+ d. difficulty in arousing

c. deep tendons reflexes 2+ With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.

A woman at 9 weeks' gestation was unable to control the nausea and vomiting of hyperemesis gravidarum through conservative measures at home. With nausea and vomiting becoming severe, the woman was omitted to the obstetrical unit. Which action should the nurse prioritize? a. bed rest with bathroom privileges b. instruct on NPO status c. establish IV for rehydration d. administration of antiemetics

c. establish IV for rehydration With severe nausea and vomiting the client may be dehydrated upon coming to hospital for assistance, so establishing an IV line is the priority intervention. This will also allow for hydration, and if needed, the administration of an antiemetic to bypass the gastrointestinal tract. Although the nurse will explain the NPO status to the client (so that vomiting may be brought under control) and the likelihood of being placed on bed rest with bathroom privileges, these teachings are not the priority.

A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion (miscarriage). The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first-trimester miscarriage? a. maternal disease b. cervical insufficiency c. fetal genetic abnormalities d. uterine fibroids (uterine myomas)

c. fetal genetic abnormalities The causes of spontaneous abortion (miscarriage) are varied and often unknown. The most common cause for first-trimester miscarriage is fetal genetic abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely causes in first trimester, and maternal disease is more likely in the second trimester. Those occurring during the second trimester are more likely related to maternal conditions, such as cervical insufficiency, congenital or acquired anomaly of the uterine cavity (uterine septum or fibroids), hypothyroidism, diabetes, chronic nephritis, use of crack cocaine, inherited and acquired thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: a. longer length of labor. b. increased number of overall pregnancies. c. increasing birth weight. d. poor quality of prenatal care.

c. increasing birth weight. Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? a. labor less than 3 hours b. hemoglobin of 11.5 mg/dl (115 g/L) c. placenta removed via manual extraction d. multiparity

c. placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage.

A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time? a. premature birth b. hypertension c. spontaneous abortion (miscarriage) d. preterm labor

c. spontaneous abortion (miscarriage) The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for spontaneous abortion (miscarriage). Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type? a. first-degree laceration b. second-degree laceration c. third-degree laceration d. fourth-degree laceration

c. third-degree laceration A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. The nurse should immediately check the client for: a. amniotic fluid infection. b. amniotic fluid embolus. c. umbilical cord prolapse. d. placental abruption (abruptio placentae).

c. umbilical cord prolapse. Because the client is not in labor, this development is considered premature rupture of membranes. The sudden onset of deep variable decelerations may indicate umbilical cord prolapse, which is an obstetric emergency that requires immediate intervention.

A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect? a. amniotic fluid embolism b. shoulder dystocia c. uterine rupture d. umbilical cord prolapse

c. uterine rupture Uterine rupture is associated with crack cocaine use disorder. Generally, the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.

A client is undergoing labor induction with intravenous oxytocin for a postterm pregnancy. The nurse is monitoring a 30-minute section of the electronic fetal monitor tracing and notes 6 contractions within a 10-minute period and a category III fetal heart tracing. Which is the priority action for the nurse to take? a. Document the findings as expected during an oxytocin induction. b. Decrease the oxytocin infusion and notify the health care provider. c. Place the client on their left side and increase intravenous (IV) hydration. d. Discontinue the oxytocin infusion and begin intrauterine resuscitation.

d. Discontinue the oxytocin infusion and begin intrauterine resuscitation. This client is exhibiting tachysystole (5 or more contractions every 10 minutes averaged over a half-hour) and an abnormal fetal heart tracing (category III tracing), so the nurse's priority is to discontinue the oxytocin infusion and begin intrauterine resuscitation measures. These findings are not expected during an oxytocin induction but should be avoided. Although it would be appropriate to notify the health care provider, the infusion should be discontinued, not decreased. Placing the client on the left side and increasing intravenous hydration are measures included in intrauterine resuscitation; however, paramount to the resuscitation is discontinuing the oxytocin infusion in order to resolve the tachysystole.

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client? a. Provide a well-lit room. b. Keep head of bed slightly elevated. c. Place the client in a supine position. d. Keep the suction equipment readily available.

d. Keep the suction equipment readily available. The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? a. Place the client in lithotomy position for birth. b. Administer oxytocin intravenously at 4 mU/minute. c. Perform artificial rupture of membranes. d. Prepare the client for a cesarean birth.

d. Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.

A nurse is interviewing a pregnant client admitted to labor and delivery for observation after a fall down some stairs. The client has several bruises on the arms, wrists, and hip. The nurse suspects that the client is a victim of intimate partner violence (IPV). To confirm those suspicions, which action is best for the nurse to take? a. Ask the client outright if they are being abused. b. Provide information about community support. c. Have a social worker come and interview the client. d. Utilize a standardized screening tool during the interview.

d. Utilize a standardized screening tool during the interview. To confirm the nurse's suspicions, the nurse should utilize a standardized tool to screen for intimate partner violence (IPV). If the tool yields positive results, the nurse can then have a social worker see the client and provide information about community support resources. Asking the client outright if they are being abused is not the best action because, for various reasons, clients often do not feel comfortable enough to disclose that fact and often require a great deal of trust before doing so.

A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth? a. extensive lacerations b. monitor for a cardiac anomaly c. assess for cleft palate d. brachial plexus assessment

d. brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia, which should be assessed and treated. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

The nurse documents for a pregnant client experiencing acute abdominal pain (above). For which health concern will the nurse plan care for this client? a. vasa previa b. placenta previa c. spontaneous abortion (miscarriage) d. disseminated intravascular coagulation (DIC)

d. disseminated intravascular coagulation (DIC) Disseminated intravascular coagulation (DIC) is a disruption of hemostasis caused by a pathologic activation of the clotting cascade that results simultaneously in blood clots and platelet and clotting factor depletion leading to bleeding. DIC is always a complication of another condition. In pregnancy, common antecedent conditions include placental abruption, which presents with severe acute abdominal pain and evidence of bleeding such as a blood clot behind the placenta as seen on ultrasound. Laboratory values that support nursing care for DIC include a low platelet count, prolonged prothrombin time, and low fibrinogen level. Bleeding from a venipuncture site is another indication of DIC. The signs and symptoms that the client experienced are not associated with vasa previa or placenta previa.

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize? a. regular heart rate and hypertension b. increased urinary output, tachycardia, and dry cough c. shortness of breath, bradycardia, and hypertension d. dyspnea, crackles, and irregular weak pulse

d. dyspnea, crackles, and irregular weak pulse The nurse should be alert for signs of cardiac decompensation due to congestive heart failure, which include crackles in the lungs from fluid, difficulty breathing, and weak pulse from heart exhaustion. The heart rate would not be regular, and a cough would not be dry. The heart rate would increase rather than decrease.

The nurse is identifying nursing diagnoses for a client with gestational hypertension. Which diagnosis would be the most appropriate for this client? a. risk for injury related to fetal distress b. imbalanced nutrition related to decreased sodium levels c. ineffective tissue perfusion related to poor heart contraction d. ineffective tissue perfusion related to vasoconstriction of blood vessels

d. ineffective tissue perfusion related to vasoconstriction of blood vessels In gestational hypertension, vasospasm occurs in both small and large arteries during pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational hypertension does not affect heart contractions.

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? a. posterior position b. firm c. closed d. shortened

d. shortened A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.