403 EXAM 3 EAQ
A client who has six living children has just given birth. After expulsion of the placenta, an infusion of lactated Ringer solution with 10 units of oxytocin is prescribed. What should the nurse explain to the client when she asks why this infusion is needed? "You had a precipitous birth." "This is required for an extramural birth." "The medication helps your uterus contract." "It will help you expel the retained fragments of your placenta."
"The medication helps your uterus contract." Multiple full-term pregnancies and births result in overstretched uterine muscles that do not contract efficiently, and bleeding may ensue. Oxytocinpromotes uterine contractions.
After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response? "It's premature separation of a normally implanted placenta." "Your placenta isn't implanted securely in place on the uterine wall." "You have premature aging of a placenta that is implanted in your uterine fundus." "The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."
"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening." Implantation of the placenta in the lower uterine segment is the accepted definition of placenta previa.
During her first prenatal visit a client tells the nurse that she needed an exchange transfusion when she was born because of Rh incompatibility. She asks the nurse whether her baby will need one also. How should the nurse respond? "Your baby has a 50% chance of being affected." "You should have no problem because you're Rh positive." "You'll be given RhoGAM, which will prevent the development of antibodies." "Your baby's cord blood will be tested to determine whether there's going to be a problem."
"You should have no problem because you're Rh positive." Rh incompatibility occurs if the mother is Rh negative and becomes sensitized and the infant is Rh positive. Because the client had Rh incompatibility, she is Rh positive, and her infant will not be affected. There is no chance that the newborn will have Rh incompatibility.
A client with poorly controlled type 1 diabetes is now in her thirty-fourth week of pregnancy. The primary healthcare provider tells her that she should have an amniocentesis at 37 weeks to assess fetal lung maturity and that induction of labor will be initiated if the fetus's lungs are mature. The client asks the nurse why an early birth may be necessary. How should the nurse reply? "You'll be protected from developing hypertension." "Your glucose level will be hard to control as you reach term." "The baby will be small enough for you to have a vaginal birth." "The chance that your baby will have hypoglycemia will be reduced."
"Your glucose level will be hard to control as you reach term." Explaining that risk to the fetus increases as the pregnancy reaches term secondary to the mother's poorly controlled diabetes provides accurate information and answers the client's direct question.
On the third postpartum day, the nurse enters the room of a client who had an unexpected cesarean birth and finds her crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" What should the nurse consider when responding? The client's feelings will pass after she has bonded with her infant. The client is probably suffering from postpartum depression and needs special care. A cesarean birth may be a traumatic experience, but most women know that it is a possible outcome. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this.
A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this. The client's response is appropriate to the situation, reflecting disappointment in not achieving her goal; in addition, this is the time when "postpartum blues" occurs.
A client is found to have gestational hypertension in the twenty-second week of gestation. Which major complication of hypertensive disease associated with pregnancy should the nurse anticipate? Placenta previa Polyhydramnios Isoimmunization Abruptio placentae
Abruptio placentae Vasospasms of placental vessels occur because of increased blood pressure. As a result the placenta may separate prematurely ( abruptio placentae).
When entering the room of a client in active labor to answer the call light, the nurse sees that she is ashen gray, dyspneic, and clutching her chest. What should the nurse do immediately after pressing the emergency light in the client's room? Administer oxygen by facemask Check for rupture of the membranes Begin cardiopulmonary resuscitation (CPR) Increase the rate of intravenous (IV) fluids
Administer oxygen by face-mask The client is exhibiting signs and symptoms of an amniotic fluid embolism; increasing oxygen intake is essential.
Which interventions should be included in the plan of care for a client with class I cardiac disease during the last weeks of pregnancy? Administering penicillin, promoting periods of rest, and daily testing of urine for protein Maintaining bed rest, administering oxygen and penicillin, and monitoring for cardiac decompensation Instituting seizure precautions and instructing the client to report dyspnea, coughing, palpitations, and increased fatigue Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor
Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor Resting and limiting stress conserve energy and reduce cardiac output. Knowing about the analgesia and anesthesia used during labor helps to relieve anxiety.
In the second hour after a client gives birth, her uterus is found to be firm, above the level of the umbilicus, and to the right of midline. What is the appropriate nursing intervention at this time? Checking for signs of retained placental fragments Massaging the uterus to prevent hemorrhage Assisting the client to the bathroom to empty her bladder Telling the client that this is a sign of uterine stabilization
Assisting the client to the bathroom to empty her bladder A full bladder commonly elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding; therefore the bladder must be emptied to maintain uterine tone.
A client comes to the clinic for a 6-week postpartum check-up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information? Providing information about a local support group Explaining that it is normal to feel depressed after childbirth Asking the client questions, using a postpartum depression scale Suggesting that the client find someone who can take care of the baby for 24 hours
Asking the client questions, using a postpartum depression scale A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. The most widely used and validated tools are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale.
Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? Carboprost tromethamine Misoprostol Nalbuphine HCl Betamethasone
Betametasone Betamethasone enhances fetal lung maturity when administered before a preterm birth.
A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? Gravida III with twins Gravida V with endometriosis Gravida II who had a 9-lb baby Gravida I who has had an intrauterine fetal death
Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease.
After the removal of a hydatidiform mole, the nurse assesses the client's laboratory data during a follow-up visit. The nurse notes that a prolonged increase of the serum human chorionic gonadotropin (hCG) level is a danger sign. Which condition is this client at increased risk of developing? Uterine rupture Choriocarcinoma Hyperemesis gravidarum Disseminated intravascular coagulation (DIC)
Choriocarcinoma hCG increases shortly after the onset of pregnancy, peaks at the end of the second month, then decreases and is sustained at a lower level until the end of pregnancy; a continued increase indicates retained trophoblastic tissue and possible choriocarcinoma.
A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for? Cord prolapse Placenta previa Chorioamnionitis Abruptio placentae
Chorioamnionitis The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection.
A nurse assesses a client in the labor room and finds that the client's Bishop score for her cervical status is 6. Which medication may be administered to this client? Oxytocin Dinoprostone Mifepristone Methylergonovine
Dinoprostone Dinoprostone is a synthetic derivative of naturally occurring prostaglandin E 2. This drug is used for cervical ripening when there is an obstetric need for labor induction.
What step should a nurse take when preparing to administer Rho(D) immune globulin to a postpartum client? Start a primary intravenous (IV) line so that the drug may be administered via IV piggyback. Ensure that the client is Rh negative and the neonate is Rh positive. Obtain a syringe and needle appropriate for the subcutaneous injection. Determine that the client has not eaten since midnight of the previous night.
Ensure that the client is Rh negative and the neonate is Rh positive. Rho(D) immune globulin is given to Rh-negative mothers not previously sensitized who have Rh-positive neonates; it prevents Rh incompatibility in the next pregnancy.
The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history? Cardiac disease Hyperthyroidism Gestational hypertension Cephalopelvic disproportion
Gestational hypertension Hypertension during pregnancy leads to vasospasm; this in turn causes the placenta to tear away from the uterine wall (abruptio placentae).
A woman's pregnancy has been uneventful, and she has gained 25 lb (11.3 kg). At term her hemoglobin level is 10.6 g/dL (106 mmol/L) and her hematocrit is 31%. What is the physiologic reason for these hemoglobin and hematocrit levels? Infection Hemodilution Nutritional deficits Concealed bleeding
Hemodilution The increase in circulating blood volume during pregnancy is reflected in lower hemoglobin and hematocrit readings (physiological anemia of pregnancy).
During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment a complete blood count and urinalysis are performed. Which laboratory finding should alert the nurse to the need for further assessment? Hemoglobin of 10 g/dL (100 mmol/L) Urine specific gravity of 1.020 Glucose level of 1+ in the urine White blood cell count of 9000/mm 3 (9 × 10 9/L)
Hemoglobin of 10 g/dL (100 mmol/L) This hemoglobin reading suggests a true anemia. The lowest hemoglobin resulting from physiologic anemia of pregnancy is 12 g/dL (120 mmol/L). This type of anemia occurs because the plasma volume increases to a greater extent than the red blood cells during pregnancy.
The nurse is reviewing a client's history. Which two predisposing causes of puerperal (postpartum) infection should prompt the nurse to monitor this client closely? Malnutrition and anemia Hemorrhage and trauma during labor Preeclampsia and retention of placental fragments Organisms in the birth canal and trauma during labor
Hemorrhage and trauma during labor Blood loss depletes the cellular response to infection; trauma provides an excellent avenue for bacteria to enter. These issues may create problems if hemorrhage occurs, because the hemoglobin and hematocrit are already low.
A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. What condition does the nurse suspect the client is experiencing? Dehydration Choriocarcinoma Hydatidiform mole Threatened abortion
Hydatidiform mole A hydatidiform mole, in which chorionic villi degenerate into grapelike vesicles, is most often the cause of these signs and symptoms.
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? In utero through the placenta In the postpartum period through breast milk During birth through contact with the maternal vagina After the birth through a blood transfusion given to the mother
In utero through the placenta Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero.
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. Which factor does the nurse suspect precipitated this preterm labor? Android pelvis Incompetent cervix First-time pregnancy Antiseizure medication
Incompetent cervix An incompetent cervix indicates a short cervix, cervical scarring from previous births, or cervical or uterine anomalies. It puts the client at risk for second-trimester spontaneous abortion.
A client's membranes ruptured 20 hours before admission. The client was in labor for 24 hours before giving birth. For which postpartum complication is this client at risk? Infection Hemorrhage Uterine atony Amniotic fluid embolism
Infection When the membranes rupture, microorganisms from the vagina may travel into the embryonic sac, causing chorioamnionitis. The longer the time between the rupture of the membranes and the birth, the greater the risk for infection.
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? Insulin needs will increase during the second trimester. Insulin needs will decrease during the second trimester. Insulin needs will not change during the second trimester. Insulin will be switched to an oral antidiabetic medication during the second trimester.
Insulin needs will increase during the second trimester. The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status. Major hormonal changes result in decreased tolerance of glucose, increased insulinresistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Increasing levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements gradually increase from about 18 to 24 weeks of gestation to about 36 weeks' gestation.
What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy? Average for gestational age, term Small for gestational age, preterm Large for gestational age, postterm Large for gestational age, near term
Large for gestational age, near term Newborns of diabetic mothers may be large for gestational age because hyperglycemia in the mother precipitates hyperinsulinism in the fetus, resulting in excess deposits of fetal fat; these infants are usually born at or before term and are large, not average or small, for gestational age.
During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. Lethargy Ambivalence Emotional lability Increased appetite Long periods of sleep
Lethargy Ambivalence Emotional Lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression.
What medication teaching does the nurse provide to a newly pregnant client with cardiac disease? Palpitations must be managed with drug therapy. Other cardiac medications will be substituted for digoxin. It is not safe to administer prophylactic penicillin during pregnancy. Maintenance dosages of cardiac medications will probably be increased.
Maintenance dosages of cardiac medications will probably be increased. During the second and third trimesters blood volume and cardiac output increase, placing a greater workload on the heart. Women with preexisting heart disease may require larger doses of cardiac medication to prevent cardiac decompensation.
A client in labor is admitted to the birthing unit 20 hours after her membranes have ruptured. Which complication should the nurse anticipate when assessing the character of the client's amniotic fluid? Cord prolapse Placenta previa Maternal sepsis Abruptio placentae
Maternal Sepsis Prolonged rupture of membranes of more than 18 hours increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection.
Which drug is administered to women after delivery to prevent postpartum uterine atony and hemorrhage but is not given to augment labor? Dinopristone Mifepristone Indomethacine Methylergonovine
Methylergonovine
The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues? Frantic energy Mild irritability Hallucinations Unwillingness to sleep
Mild irritability Postpartum blues are transient symptoms that a client may experience after childbirth. About 85% of women experience postpartum blues with symptoms of mild irritability, tearfulness, rapid mood fluctuations, and anxiety.
A 36-year-old primigravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, which nursing intervention is of the highest importance at this time? Medication: magnesium sulfate 40g/1000mL, LR 2g/hr IV Vitals: temp 98.2, pulse 68, RR 14, BP 140/110 Physical assessment: reflexes 3+, urinary protein 3+, urinary output 190mL in 8hr, pedal edema 3+, client reports blurred vision, severe headache, and epigastric pain Assessing the fetal heart rate for tachycardia Promoting adequate urine output by offering oral fluids Monitoring respiratory status and ascertaining that calcium gluconate is at the bedside Notifying the primary healthcare provider regarding the epigastric pain, headache, and blurred vision
Notifying the primary healthcare provider regarding the epigastric pain, headache, and blurred vision Epigastric pain, blurred vision, and headache are prodromal symptoms of eclampsia in a client with preeclampsia. Minimal urine output in 8 hours would be 240, or 30 mL/hr. The risk for a tonic-clonic seizure increases dramatically, and death is possible.
The nurse determines that a postpartum client is gravida 1, para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care? Obtaining a prescription for Rho (D) immune globulin Determining the father's blood type Checking for signs of ABO incompatibility Obtaining blood for type and cross-matching
Obtaining a prescription for Rho (D) immune globulin Rho (D) immune globulin will prevent sensitization from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive infant. Because the newborn has type O blood with no ABO incompatibility, neither mother nor infant will require a transfusion; this is the mother's first pregnancy, so the risk for RH incompatibility is minimal.
A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. Select all that apply. Oxytocin Misoprostol Ergonovine Carboprost Dinoprostone
Oxytocin Misoprostol Dinoprostone
A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. Which characteristic typical of placenta previa supports the nurse's conclusion? Painful vaginal bleeding in the first trimester Painful vaginal bleeding in the third trimester Painless vaginal bleeding in the first trimester Painless vaginal bleeding in the third trimester
Painless vaginal bleeding in the third trimester As the lower uterine segment stretches and thins, painless tearing and bleeding occur at the low implantation site.
A newborn is admitted to the nursery. The newborn weighs 10 lb, 2 oz (4592 g), which is 2 lb (907 g) more than the birthweight of any of the neonate's siblings. Which intervention should the nurse implement in relation to this baby's birth weight? Document the findings Delay starting oral feedings Perform serial glucose readings Place the newborn in a heated crib
Perform serial glucose readings A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia, because maternal glucose is no longer available.
A client at 42 weeks' gestation is admitted for a nonstress test. The nurse concludes that this test is being done because of what possible complication related to a prolonged pregnancy? Polyhydramnios Placental insufficiency Postpartum infection Subclinical gestational diabetes
Placental Insufficiency Placental function peaks at 37 weeks and declines slowly thereafter; therefore continuation of the pregnancy past term (42 weeks) places the fetus at risk because of placental insufficiency.
A young pregnant adolescent is diagnosed as having bacterial vaginosis. What further complications related to bacterial vaginosis may occur during pregnancy? Select all that apply. Neonatal sepsis Cervical dysplasia Preterm labor and birth Intraamniotic infection Postpartum endometritis
Preterm labor and birth Intraamniotic infection Postpartum endometritis Preterm birth and labor may occur because bacteria that enters the cervix irritates the uterus, which cause contractions. Bacterial vaginosis is associated with high risk of intraamniotic infection and postpartum endometritis.
A pregnant woman with a history of heart disease visits the prenatal clinic toward the end of her second trimester. Which intervention does the nurse anticipate will be part of this client's care plan? Preparation for a cesarean birth Bed rest during the last trimester Prophylactic antibiotics at the time of birth Increasing dosages of cardiac medications as pregnancy progresses
Prophylactic antibiotics at the time of birth Prophylactic antibiotics are given to clients with heart disease to reduce their risk for bacterial endocarditis.
The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement? Teaching the client about normal newborn care Ensuring adequate bonding time with the infant Giving the client time and space to express her feelings Referring the client to a psychiatric healthcare provider as prescribed
Referring the client to a psychiatric healthcare provider as prescribed Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse. A mother who experiences this condition must be referred to a specialist for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention to prevent suicide or infanticide.
Rho(D) immune globulin (RhoGAM) is prescribed for an Rh-negative client who has just given birth. Before giving the medication, the nurse verifies the newborn's Rh factor and reaction to the Coombs test. Which combination of newborn Rh factor and Coombs test result confirms the need to give Rho(D) immune globulin? Rh positive with a positive Coombs result Rh positive with a negative Coombs result Rh negative with a positive Coombs result Rh negative with a negative Coombs result
Rh positive with a negative Coombs result All Rh-negative mothers with Rh-positive infants are candidates for Rho(D) immune globulin; a negative Coombs test result verifies an absence of Rh antibodies, indicating that the Rho(D) immune globulin will be effective in preventing antibody formation during the client's next pregnancy.
A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What objective clinical finding indicates an impending seizure? Persistent headache with blurred vision Epigastric pain with nausea and vomiting Spots and flashes of light before the eyes Rolling of the eyes to one side with a fixed stare
Rolling of the eyes to one side with a fixed stare Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure.
A pregnant client has class II cardiac disease. To best plan the client's care, what does the nurse anticipate for the client? May participate in as much activity as she desires Should be hospitalized if there is evidence of cardiac decompensation Will have to maintain bed rest for most of the day throughout her pregnancy May have to consider a therapeutic abortion if there is evidence of cardiac decompensation
Should be hospitalized if there is evidence of cardiac decompensation Clients with cardiac disease should be taught the signs and symptoms of cardiac decompensation; if they occur, the client should stop the activity that precipitated them and notify the primary healthcare provider.
A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can't take this anymore." The husband calls the women's health clinic and asks what he should do. What is the best response by the nurse? Telling him that his wife may be suffering from depression and needs emergency care Telling him that fatigue is expected and that his wife needs to take rest periods during the day Reassuring him that his wife is experiencing postpartum blues that will lessen in several days Advising him to make an appointment for his wife to see her primary healthcare provider if the problem continues
Telling him that his wife may be suffering from depression and needs emergency care The mother's inability to care for herself or her children is an ominous sign that postpartum depression is reaching a critical level. The woman needs immediate care to meet her needs and ensure the safety of the children. Between 10% and 15% of new mothers have postpartum depression within 4 weeks of the birth of an infant.
In which clinical situation would cervical ripening drugs be prescribed to pregnant women? There is a need for a termination of pregnancy. The cervical status indicates a Bishop score of 6. Uterine contractions occur after 25 weeks of gestation. Uterine contractions occur after 18 weeks of gestation.
The cervical status indicates a Bishop score of 6. Cervical-ripening drugs are used to soften the cervix and improve uterine muscle tone. The cervical status of a Bishop score of 6 indicates a need for cervical-ripening drugs such as dinoprostone.
What assessments should be done before administering uterine stimulants to induce labor? Select all that apply. The cervix must be ready for labor induction. Sympathomimetic drugs can be administered. An intrauterine device for birth control can be used. The fetal heart rate and contractions should be documented. The mother's blood pressure, pulse rate, and respirations should be assessed.
The cervix must be ready for labor induction. The fetal heart rate and contractions should be documented. The mother's blood pressure, pulse rate, and respirations should be assessed. Cervical ripening is important for the induction of labor and delivery of the fetus. The fetal heart rate should be documented to assure the safety of the fetus. The mother's vital signs should be monitored regularly to detect medical conditions.
A client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. What information about the client's activities in the history indicates to the nurse that there is a need for this test? The client cares for a neighbor's cat The client works as a dog trainer The client uses chemical cleaners The client consumes raw vegetables
The client cares for a neighbor's cat Toxoplasmosis is caused by a protozoal parasite; cats acquire the organism by ingesting infected mice or birds, and the cysts are found in their feces.
Which statements relate to preterm labor? Select all that apply. A premature baby has good cognitive development. The treatment for preterm labor includes bed rest and hydration. Preterm labor before the 20th week is indicative of a nonviable fetus. It is not desirable to stop the delivery in the case of preterm labor. Preterm labor refers to uterine contractions progressing to delivery before the 27th week of pregnancy.
The treatment for preterm labor includes bed rest and hydration. Preterm labor before the 20th week is indicative of a nonviable fetus. Bed rest and hydration are nonpharmacological interventions for treating preterm labor. Early labor pains before 20th week are indicative of a nonviable fetus and should generally be uninterrupted.
The nurse in the birthing unit is caring for several postpartum clients. Which factor will increase the risk for hypotonic uterine dystocia? Twin gestation Gestational anemia Hypertonic contractions Gestational hypertension
Twin Gestation A multiple gestation thins the uterine wall by overstretching it; therefore the efficiency of contractions is reduced.
Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client? Hypertension Uterine atony Thrombophlebitis Uncontrolled bleeding
Uncontrolled Bleeding DIC is associated with amniotic fluid embolism (also known as anaphylactoid syndrome of pregnancy); both problems may occur after premature separation of the placenta.
Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion.
Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. In the left-lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase.
What complication should a nurse be alert for in a client receiving an oxytocin infusion to induce labor? Intense pain Uterine tetany Hypoglycemia Umbilical cord prolapse
Uterine tetany Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
A client has been receiving oxytocin to augment labor. For what adverse reaction caused by a prolonged oxytocin infusion should the nurse monitor the client? Change in affect Hyperventilation Water intoxication Increased temperature
Water Intoxication Oxytocin, a posterior pituitary hormone, has an antidiuretic effect, acting to reabsorb water from the glomerular filtrate.
Which clinical finding does the nurse expect when assessing a client with abruptio placentae? Flaccid uterus Painless bleeding Boardlike abdomen Bright red bleeding
board-like abdomen Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots.
A client who is at risk for seizures as a result of severe preeclampsia is receiving an intravenous infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. Proteinuria Epigastric pain Respirations of 10 breaths/min Loss of patellar reflexes Urine output of 40 mL/hr
espirations of 10 breaths/min Loss of patellar reflexes A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia.
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. Headache Constipation Abdominal pain Vaginal bleeding Flulike symptoms
headache abdominal pain flulike symptoms Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.
The primary healthcare provider diagnoses placenta previa in a primiparous client. What does this indicate to the nurse regarding the condition of the placenta? Infarcted Low-lying Immaturely developed Separating prematurely
low-lying Implantation should occur in the upper third of the uterus; a low-lying placenta is termed placenta previa.
A nurse who is caring for a postpartum client expresses concern because the woman is at increased risk for hemorrhage. Which factor in the client's history alerted the nurse to this concern? Multifetal pregnancy Short duration of labor Previous cesarean birth Age older than 40 years
multifetal pregnancy Overdistention of the uterus because of a large fetus, multiple gestation, or hydramnios predisposes a woman to uterine atony, which may cause postpartum hemorrhage.
The nurse is caring for a client during the early postpartum period. The client alerts the nurse that she is experiencing severe pain. The nurse interviews the client, obtains her vital signs, and performs a physical assessment. What does this assessment most likely reveal? Vitals: temp 99, pulse 108, RR 20, BP 105/60 physical assessment: episiotomy surrounded by edema and ecchymosis, firm fundus, no lochia present client interview: reports severe perineal and rectal pressure Uterine infection Urinary infection Vaginal hematoma Postpartum hemorrhage
vaginal hematoma These are the classic signs and symptoms of a vaginal hematoma.
A client is admitted to the labor and delivery unit for labor augmentation with oxytocin. She is postterm at 40 weeks, 3 days, and has gestational diabetes. The cervix is dilated to 2 cm and 90% effaced. The primary healthcare provider performed an amniotomy to permit internal electronic fetal monitoring. The amniotic fluid is pale yellow and moderate in amount. Immediately after the amniotomy the nurse will assess the fetal heart rate for at least 1 full minute for signs of what? Infection Uterine atony Uterine cord prolapse Maternal hypertension
uterine cord prolapse The umbilical cord can slip down during after the amniotomy and be compressed between the fetal presenting part and the client's pelvis. Cord compression is suspected if deep or prolonged variable decelerations occur during contractions or if persistent bradycardia is present after contractions.
