Blue print 2- family process

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the sex of the fetus can be determined as early as which week? 6 8 12 20

12 By the end of the twelfth week of gestation, the fetal sex can be determined by the appearance of the external genitalia on ultrasound; therefore, the other options are incorrect.

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 5 weeks 9 weeks 13 weeks 18 weeks

18 weeks The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until 18 weeks' gestation or later, as she has no prior experience and the uterus has not been previously stretched during pregnancy adaptation. The first recognition of fetal movement is called quickening.

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make? Between 6 and 8 weeks Between 8 and 10 weeks Between 12 and 14 weeks Between 16 and 20 weeks

Between 16 and 20 weeks Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity. Therefore, the remaining options are incorrect.

A pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. Which activity should the nurse tell the client to perform when the cramps occur? Dorsiflex the foot while flexing the knee. Dorsiflex the foot while extending the knee. Plantar flex the foot while flexing the knee. Plantar flex the foot while extending the knee.

Dorsiflex the foot while extending the knee. Leg cramps occur when the pregnant client stretches the leg and plantar flexes the foot. Dorsiflexing the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Therefore, the other activities are incorrect.

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? Hypertension Low-grade fever Generalized edema Increased pulse rate

Hypertension A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions.

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. Lethargy Sleepiness Irritability Constant crying Difficult to comfort Cuddles when being held

Irritability Constant crying Difficult to comfort A newborn of a woman who uses drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held. This infant is not lethargic or sleepy.

The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching? "Cool sitz baths will help in relieving the discomfort." "I should perform Kegel exercises as you have instructed." "I should apply heat packs to the hemorrhoids to help them shrink." "I can apply ice packs to the hemorrhoids to assist in relieving discomfort."

"I should apply heat packs to the hemorrhoids to help them shrink." Hot packs will increase the blood flow to the area and worsen the discomfort from hemorrhoids. Remedies for the symptoms of hemorrhoids include ice packs, warm or cold sitz baths, gentle cleansing, and topical ointments and anesthetic agents. Kegel exercises help to strengthen the perineum.

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? "I should avoid between-meal snacks." "I should lie down for an hour after eating." "I should use spices for cooking rather than using salt." "I should avoid eating foods that produce gas and fatty foods."

"I should avoid eating foods that produce gas and fatty foods." Lying down is likely to lead to reflux of stomach contents, especially immediately after a meal. The client should be instructed to avoid spices, along with salt, because spices trigger heartburn. Salt produces edema. The client should be encouraged to eat between-meal snacks and should be instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating 3 large meals. The client also should limit or avoid gas-producing and fatty foods.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? A normal test result An abnormal test result A high risk for fetal demise The need for a cesarean section

A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations.

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved? Pink mucous membranes Increased vaginal secretions Complaints of daily headaches and fatigue Complaints of increased frequency of voiding

Complaints of daily headaches and fatigue Anemia is one of the most common problems in pregnancy, and iron deficiency anemia and folic acid deficiency anemia are 2 of the most common types. It is estimated that between 20% and 60% of all women are anemic at some point during pregnancy, with hemoglobin concentration lower than 10.0 to 11.0 g/dL (100 to 110 mmol/L). Complaints of daily headaches and fatigue are abnormal findings and may reflect complications caused by decreased oxygen supply to vital organs, thus supporting laboratory findings. The incorrect options are expected findings in the first trimester of pregnancy.

A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms? Eating a high-fat diet Increasing fluids with meals Eating a high-carbohydrate diet Eating dry crackers before arising

Eating dry crackers before arising Some strategies for decreasing morning nausea are keeping crackers, Melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats; and consuming adequate fluid between meals but not with meals. A high-carbohydrate diet could increase the episodes of nausea.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse should provide the client with which information? Glucose crosses the placenta Insulin crosses the placenta Increased caloric intake is needed Decreased caloric intake is required

Glucose crosses the placenta Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin and is referred to as the diabetogenic effect of pregnancy. Caloric requirements are not affected by diabetes.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? Developmental delays because of excessive size Maintaining safety because of low blood glucose levels Choking because of impaired suck and swallow reflexes Elevated body temperature because of excess fat and glycogen

Maintaining safety because of low blood glucose levels The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problem

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? Monitoring the newborn's vital signs routinely Maintaining standard precautions at all times while caring for the newborn Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

Maintaining standard precautions at all times while caring for the newborn An infant born to a mother infected with HIV must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn. Mothers infected with HIV should not breast-feed.

The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? Eat only when hungry. Eliminate snacks during the day. Avoid meals in fast-food restaurants. Monitor for appropriate weight gain patterns.

Monitor for appropriate weight gain patterns. The nurse should teach the adolescents about appropriate weight patterns and how to monitor these patterns. The adolescent is more likely to follow suggestions and adhere to the appropriate dietary patterns if the nurse explains why the weight gain is important for the fetus and the mother. Advising an adolescent to eat only when hungry could lead to a deficit in nutrients. Telling an adolescent to avoid fast-food restaurants and eliminate snacks may cause the adolescent to rebel.

The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which drink? Tea Milk Coffee Orange juice

Orange juice Foods containing ascorbic acid will increase the absorption of iron. Calcium and phosphorus in milk and tannin in tea decrease iron absorption. Caffeine in coffee binds iron and prevents it from being fully absorbed. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements.

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction? Increase daily calories to ensure weight gain. Maintain a supine position during rest periods. Restrict visitors who may have an active infection. Avoid becoming concerned about placing stress on the heart.

Restrict visitors who may have an active infection. The client should avoid exposure to infection and not allow persons with active infections to visit. Too much weight gain causes an increase in body requirements and increases stress on the heart. The client should rest on the left side to promote blood return. Stress causes increased heart workload, with the potential for adverse consequences.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor? The appearance of the fetal external genitalia The beginning of differentiation in the fetal groin The fetal testes are descended into the scrotal sac The internal differences in males and females become apparent

The appearance of the fetal external genitalia Between weeks 16 and 20, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes begin to descend into the scrotal sac at the end of the 38th week. Internal differences in the male and female occur at the end of the seventh week.

he nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? The client's last baby weighed 10 pounds at birth. The client's previous deliveries were by cesarean section. The client has a family history of cardiovascular disease. The client is 5 feet, 3 inches tall and weighs 165 pounds.

The client's last baby weighed 10 pounds at birth. Known risk factors that increase the risk of developing gestational diabetes include obesity (more than approximately 198 pounds, depending on height), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (greater than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes.

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? "I don't like my figure anymore. My clothes are all too tight." "I don't like my breasts anymore. These silver lines are ugly." "I don't like my stomach anymore. That brown line is disgusting." "I don't like my face anymore. I always look like I have been crying."

"I don't like my face anymore. I always look like I have been crying." In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriatefor this client? A private room across from the elevator A semiprivate room across from the nurses' station A private room 2 doors away from the nurses' station A semiprivate room with another client who enjoys watching television

A private room 2 doors away from the nurses' station A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room 2 doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia. The client with severe preeclampsia requires intense nursing observation and care.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? Length of 19 inches Abnormal palmar creases Birth weight of 6 lb, 14 oz (3120 g) Head circumference appropriate for gestational age

Abnormal palmar creases Fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum disorders (FASDs), is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? Strict bed rest is required after the procedure. Hospitalization is necessary for 24 hours after the procedure. An informed consent needs to be signed before the procedure. A fever is expected after the procedure because of the trauma to the abdomen.

An informed consent needs to be signed before the procedure. Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the obstetrician's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? Checking for edema Monitoring daily weight Monitoring the apical pulse Monitoring the temperature

Monitoring the apical pulse Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Edema and weight gain are more of a concern for the client with preeclampsia or gestational hypertension, and an elevated temperature is an indicator of infection.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. Proteinuria Hypertension Low-grade fever Generalized edema Increased pulse rate Increased respiratory rate

Proteinuria Hypertension The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.

The nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? She will feel some pain during the procedure. She will be placed in a supine left side-lying position. She will feel some pressure when the vaginal probe is moved. She will need to drink 2 quarts of water to attain a full bladder.

She will feel some pressure when the vaginal probe is moved. Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

he nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid? Cheese Spinach Potatoes Bananas

Spinach Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least 4 servings of folic acid-rich foods per day. Food items high in folic acid include glandular meats, yeast, legumes, whole grains, and dark green leafy vegetables. Milk products and cheese supply calcium, potatoes provide vitamin B6, and bananas provide potassium.

Which data places the client at risk for developing gestational diabetes during pregnancy? The client has a family history of type 1 diabetes. The client is 5 feet tall and weighs 129 lb. The client's previous deliveries were by cesarean section. The client has a history of gestational diabetes with her previous pregnancy.

The client has a history of gestational diabetes with her previous pregnancy. Known risk factors that increase the risk of developing gestational diabetes include obesity (more than 198 lb), chronic hypertension, family history of type 2 diabetes, previous birth of a large infant (more than 4000 g), and gestational diabetes in a previous pregnancy. The other options are not risk factors associated with the development of gestational diabetes.

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? "I will be sure to wash my hands before and after bathroom use." "I need to breast-feed, especially for the first 6 weeks postpartum." "Support groups are available to assist me with understanding my diagnosis of HIV." "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

"I need to breast-feed, especially for the first 6 weeks postpartum." The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the prenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. In the United States and most developed countries, HIV-positive clients are encouraged to bottle-feed their infants (the primary health care provider's prescription is always followed). Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? "I will record the number of movements or kicks." "I need to lie flat on my back to perform the procedure." "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

"I need to lie flat on my back to perform the procedure." The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the primary health care provider (PHCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the PHCP.

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? "I don't like dairy products." "I will continue drinking my afternoon milkshake." "I'm not used to eating so much food, but I will try." "I want to gain only 10 pounds because I want to have a small, petite baby."

"I want to gain only 10 pounds because I want to have a small, petite baby." Pregnant adolescents are at higher risk for complications. Peer pressure is an important influence on nutritional status. Adolescents often are concerned about their body image. If weight is a major focus for the adolescent, the adolescent is more likely to restrict calories to avoid weight gain. The correct option is the only one that suggests a possible psychosocial problem. The remaining options relate to physiological issues.

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. Assess blood pressure. Check the urine for protein. Assess deep tendon reflexes. Discuss the need for hospitalization. Teach the importance of keeping track of a daily weight.

Assess blood pressure. Check the urine for protein. Assess deep tendon reflexes. Teach the importance of keeping track of a daily weight. With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the woman would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition.

The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid? Pork Cheese Chicken Dried peas

Dried peas Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Pork, cheese, and chicken are not high in folic acid. Pork is a good source of thiamine. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein.

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? Hematocrit 38% (0.38) Glucose 86 mg/dL (4.8 mmol/L) Hemoglobin 9 g/dL (90 mmol/L) White blood cell count 12,400 mm3 (12.4 × 109/L)

Hemoglobin 9 g/dL (90 mmol/L) Pica practices often lead to iron deficiency anemia, resulting in a decreased hemoglobin level. The laboratory values in options 1, 2, and 4 are normal for the pregnant client.

The nurse is describing cardiovascular system changes that occur during pregnancy to a client. Which findings are normal for a client in the second trimester? Select all that apply. Increase in pulse rate Increase in blood pressure Frequent bowel elimination Increase in red blood cell production Decrease in white blood cell production

Increase in pulse rate Increase in red blood cell production Numerous cardiovascular adaptations occur during pregnancy. Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/minute, which then persists to term. During pregnancy, there is an accelerated production of red blood cells. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg until 24 to 32 weeks. The blood pressure by term usually is no higher than the prepregnancy level. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus.

The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? Milk Yogurt Bananas Leafy green vegetables

Leafy green vegetables Leafy green vegetables are rich in folate (folic acid). Milk and yogurt supply calcium; bananas provide potassium.

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? Monitor for fetal movement. Monitor the maternal blood glucose. Instruct the client to maintain complete bed rest. Instruct the client to restrict dietary sodium and any food items that contain sodium.

Monitor for fetal movement. A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary.

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? Avoid wearing a bra. Wash the breasts with warm water and keep them dry. Wear tight-fitting blouses or dresses to provide support. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.

Wash the breasts with warm water and keep them dry. The pregnant client should be instructed to wash the breasts with warm water and keep them dry. The client should be instructed to avoid using soap on the nipples and areolar area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses cause discomfort. The client is instructed to wear soft-textured clothing to decrease nipple tenderness and to use breast pads inside the bra to prevent leakage through the clothing if colostrum is a problem.

The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? Milk Potatoes Cantaloupe Whole-grain cereal

Whole-grain cereal Dietary sources of iron include lean meats; liver; shellfish; dark green, leafy vegetables; legumes; whole grains and enriched grains; cereals; and molasses. Milk is high in calcium and also contains phosphorus. Potatoes and cantaloupe are high in vitamin C.

A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? "The test is a procedure that will require an informed consent to be signed." "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." "The test is done to see if the baby can handle the stress of labor, and medicine is given to make the uterus contract." "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

"A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen." The nonstress test takes about 20 to 30 minutes. The test is termed nonstress because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions (medication is not given) to obtain the necessary data. The test is noninvasive (an informed consent is not required), and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen, where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement also is secured to the maternal abdomen. Fetal heart activity and movements are recorded.

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

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

During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? "Diet and insulin needs change during pregnancy." "I will plan my diet based on the results of urine glucose testing." "I will need to eat 600 more calories every day because I am pregnant." "I can continue with the same diet as before pregnancy, as long as it is well balanced."

"Diet and insulin needs change during pregnancy." The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. An increase of 600 calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the second and third trimesters, insulin needs increase.

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? "It is best that I rest lying on my side to promote blood return to the heart." "I need to avoid excessive weight gain to prevent increased demands on my heart." "I need to try to avoid stressful situations because stress increases the workload on the heart." "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Resting should be done by lying on the side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased heart workload, and the client should be instructed to avoid stress.

The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching? "It is best that I rest on my left side to promote blood return to the heart." "I need to avoid excessive weight gain to prevent increased demands on my heart." "I need to try to avoid stressful situations because stress increases the workload on the heart." "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Resting should be done while lying on the left side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased workload on the heart, and the client should be instructed to avoid stress.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? "I should stay on the diabetic diet." "I should perform glucose monitoring at home." "I should avoid exercise because of the negative effects on insulin production." "I should be aware of any infections and report signs of infection immediately to my obstetrician."

"I should avoid exercise because of the negative effects on insulin production." Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.

A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs? "My weight gain is not important." "I should avoid stressful situations." "I should rest by lying on my back." "There is no restriction on people who visit me."

"I should avoid stressful situations." Stress causes increased heart workload, and the client should be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return and avoid supine hypotension. To avoid infections, individuals with active infections should not be allowed to visit the client. Otherwise, restrictions are not required.

A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement? "I should drink 12 glasses of fruit juices and milk every day." "I should drink 8 to 10 glasses of fluid a day, and I can drink as many diet soft drinks as I want." "I should drink 12 glasses of fluid a day, and I can include the coffee or tea that I drink in the count." "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water."

"I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water." The nurse should instruct the client to have an adequate fluid intake daily to assist in digestion and in the management of constipation. The pregnant client should consume at least 8 to 10 (8-oz) glasses of fluid each day, of which at least 6 glasses should be water. It is not necessary for the client to drink 12 glasses of fruit juices and milk every day. Because of their sodium content, diet soft drinks should be consumed in moderation. Caffeinated beverages have a diuretic effect, which may be counterproductive to increasing fluid intake.

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching? "I should lie on my back to perform the procedure." "I will use a clock or a timer and record the number of movements or kicks." "I should count the fetal movements for 30 to 60 minutes 3 times a day." "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

"I should lie on my back to perform the procedure." The client should lie on her side, not her back, when performing kick counts. Lying on the back increases the risk for vena cava syndrome. The client should use a timer or a clock and should record the number of movements felt during that time. The client is advised to count the fetal movements for 30 to 60 minutes 3 times a day. The client is instructed to place her hands on the largest part of her abdomen and concentrate on the fetal movements.

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? "I will place my baby's crib close to the door." "Some health care personnel won't have name badges." "I will ask the nurse to attend to my infant if I am napping and my husband is not here." "It's okay to allow the nurse assistant to carry my newborn to the nursery."

"I will ask the nurse to attend to my infant if I am napping and my husband is not here. Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 4 are incorrect and indicate that the mother needs further teaching.

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? "I will drink 8 oz of water with each meal." "I will eat 3 servings of cracked wheat bread each day." "I will eat 2 saltine crackers before I get up each morning." "I will eat fresh fruits and vegetables for snacks and for dessert each day."

"I will eat fresh fruits and vegetables for snacks and for dessert each day." Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? "I will need to increase my insulin dosage during the first 3 months of pregnancy." "My insulin dose will likely need to be increased during the second and third trimesters." "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

"I will need to increase my insulin dosage during the first 3 months of pregnancy." Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates an understanding of self-care for this diagnosis? "I need to eat fruits and vegetables only." "I will go to the laboratory daily for a glucose test." "I cannot exercise because of the negative effects on insulin production." "I will report signs of infection immediately to my primary health care provider."

"I will report signs of infection immediately to my primary health care provider." Signs of infection need to be reported immediately to the primary health care provider because of the risk of complications. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet that is balanced with all food groups. Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Many women are taught to perform blood glucose monitoring. If the woman is not performing the blood glucose monitoring at home, it is not necessary for the woman to report to the laboratory daily for a blood test.

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions? "Iron supplements may give me constipation." "All foods with protein lack iron and should be avoided." "The iron is best absorbed if taken at breakfast with some food." "My body has all of the iron it needs, and I don't need to take supplements."

"Iron supplements may give me constipation." Iron is needed both to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and the hematocrit level. This is a normal adaptation and is known as physiological anemia of pregnancy. Therefore, supplements are needed. Iron supplements usually cause constipation. One food source of protein is meats and are an excellent source of iron. Iron is best absorbed if taken on an empty stomach.

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? "My vision for the past 2 days has been really fuzzy." "The swelling in my hands and ankles has gone down." "I had heartburn yesterday after I ate some spicy foods." "I had a headache yesterday, but I took some acetaminophen and it went away."

"My vision for the past 2 days has been really fuzzy." Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia.

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client? "Your OGTT results indicate that your baby is at high risk for macrosomia, and special considerations may be necessary at delivery." "Your OGTT results are within normal limits, but continuing your prenatal visits remains essential to monitor fetal growth and development." "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." "Your OGTT results indicate that you are positive for gestational diabetes. You will be scheduled for a dietitian consultation to plan your daily dietary intake."

"The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." Recommendations for gestational diabetes mellitus (GDM) screening during pregnancy indicate that women should be screened using the 1-hour OGTT at 24 to 28 weeks' gestation. The OGTT is a screening tool, and when results are greater than 140 mg/dL (8 mmol/L) the recommendation is further assessment via the 3-hour OGTT. Although fetal macrosomia is associated with maternal glucose intolerance, this diagnosis cannot be made with a 1-hour OGTT, thus eliminating option 1. Option 2 indicates that the OGTT results are within normal limits and therefore can be eliminated because the client's 1-hour OGTT results exceed the normal level. Only when 2 or more of the 4 measured glucose levels are exceeded can a woman be diagnosed with GDM. This fact eliminates option 4.

A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? "You should not worry about your baby's condition after the delivery because complications are rare." "Your baby will probably need to spend a few days in the neonatal intensive care unit after delivery." "You will not have any problems if you follow all the advice the primary health care provider has given you." "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red blood cell volume, hemoglobin level, and iron stores. Telling a client that she will not have any problems if she follows the primary health care provider's advice and telling her that she should not worry because complications are rare provide false reassurance to the client. Telling the client that the baby will probably spend time in the neonatal intensive care unit will cause further concern. The correct option provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the client.

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? "Iron supplements will give me diarrhea." "Meat does not provide iron and should be avoided." "The iron is best absorbed if taken on an empty stomach." "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement."

"The iron is best absorbed if taken on an empty stomach." Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.

A primary health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy, and the client asks the nurse about the procedure. How should the nurse respond to the client? "The procedure takes about 2 hours." "It will be necessary to drink 1 to 2 quarts (1 to 2 liters) of water before the examination." "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture."

"The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a ge Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 4 identify components of abdominal ultrasound.

A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response? "This test measures your ability to tolerate the pregnancy." "This test measures amniotic fluid volume and fetal activity." "This test measures your cardiac status and ability to tolerate labor." "This test measures only the amount of amniotic fluid present in the uterus."

"This test measures amniotic fluid volume and fetal activity." The BPP assesses 5 parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a BPP, each of the 5 parameters contributes 0 to 2 points, with a score of 8 considered normal and a score of 10 perfect. Results are available immediately. A BPP test deals with fetal, not maternal, well-being. Options 1 and 3 relate to maternal well-being. Amniotic fluid measurement is only 1 component of the BPP test.

The nurse provides teaching on how to relieve discomfort to a client in her second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching? "When I get home I should lie on my left side, with my feet in a dorsiflexed position." "I should soak in a tub bath of hot water when I get home and then perform pelvic tilt exercises." "When I get home I should lie on my right side, with my feet elevated on a pillow, and put a heating pad on my back." "When I get home I should lie on the floor, with my legs elevated on a couch, and turn my hips and knees at right angles."

"When I get home I should lie on the floor, with my legs elevated on a couch, and turn my hips and knees at right angles." Lying on the floor with the legs elevated on a couch with the hips and knees at right angles will produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of the lower extremities. Lying on the left side with the feet dorsiflexed may help with the reduction of hemorrhoids. Remember that heat needs to be prescribed by a primary health care provider (PHCP).

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider (PHCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the PHCP has documented the results as negative. How should the nurse interpret this finding? A normal test result An abnormal test result A high risk for fetal demise The need for a cesarean delivery

A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Repetitive late decelerations render the test results positive.

A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching? Select all that apply. Uterine contractions are stimulated by Leopold's maneuvers. An external fetal monitor is attached, and the woman ambulates on a treadmill until contractions begin. An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation. Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions.

An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation. A contraction stress test assesses placental oxygenation and function, determines fetal ability to tolerate labor, determines fetal well-being, and is performed if the nonstress test is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is then stimulated to contract by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation until 3 palpable contractions of 40 seconds or longer in a 10-minute period have occurred. Frequent maternal blood pressure readings are taken, and the client is monitored closely while increasing doses of oxytocin are given. Leopold's maneuvers help to determine fetal position and presentation. A treadmill is not used for a contraction stress test. Internal fetal monitoring is not possible until membranes have been ruptured.

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? Apply heat to the affected area. Take acetaminophen every 4 hours. Self-administer calcium carbonate tablets 3 times daily. Purchase a chewable antacid that contains calcium and take a tablet with each meal.

Apply heat to the affected area. Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. For the pregnant woman who complains of leg cramps, the nurse should perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse should instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The primary health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse should not prescribe these or any other medications.

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium? Broccoli Creamed spinach Pasta with parmesan cheese Freshly squeezed orange juice

Broccoli The best source of calcium is dairy products. Cheese is a dairy product and cannot be eaten when the client has lactose intolerance; therefore, women with lactose intolerance need other sources of calcium. Calcium is present in dark green leafy vegetables, broccoli, legumes, nuts, and dried fruits. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. In addition, creamed spinach may not be tolerated by a client with lactose intolerance. Orange juice does not contain significant amounts of calcium unless it has been fortified with calcium.

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? Tongue blade Percussion hammer Potassium chloride injection Calcium gluconate injection

Calcium gluconate injection oxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest priority item. Potassium chloride is not related to the administration of magnesium sulfate.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? Feed the newborn less frequently. Continue to breast-feed every 2 to 3 hours. Switch to bottle-feeding the infant for 2 weeks. Stop breast-feeding and switch to bottle-feeding permanently.

Continue to breast-feed every 2 to 3 hours. Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 3 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. `Cyanosis Tachypnea Hypotension Retractions Audible grunts Presence of a barrel chest

Cyanosis Tachypnea Retractions Audible grunts A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Hypotension and a barrel chest are not clinical manifestations associated with respiratory distress syndrome.

The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that it is 37.3º C (99.2º F). Based on this finding, which nursing action is most appropriate? Document the temperature. Notify the primary health care provider. Retake the temperature by the rectal route. Inform the client that the temperature is elevated and antibiotics may be required.

Document the temperature. The normal temperature during pregnancy is 36.2º C to 37.6º C (98º F to 99.6º F). This slight elevation occurs because of the increased metabolic effect that occurs as a result of pregnancy. A temperature greater than this may suggest an infection that could require medical management. The remaining options are unnecessary.

The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? Soft cheese Dried fruits Creamed spinach Fresh-squeezed orange juice

Dried fruits The best source of calcium is dairy products. Women with lactose intolerance need other sources of calcium. Calcium is present in dark green leafy vegetables, broccoli, legumes, nuts, and dried fruits. Soft cheese is a dairy product and is not tolerated well by the client with lactose intolerance. Some hard cheeses are well aged and may be permissible on a lactose-free diet. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. In addition, creamed spinach may not be tolerated by a client with lactose intolerance. Orange juice does not contain significant amounts of calcium unless fortified with calcium.

The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? Consume a low-fiber diet. Drink 8 glasses of water per day. Use a Fleet enema when the episodes occur. Take a mild stool softener daily in the evening.

Drink 8 glasses of water per day. The nurse should instruct the client to drink at least 8 to 10 (8-oz) glasses of fluid each day, of which 4 to 6 glasses are water, and to consume a diet that includes fiber to prevent constipation. The client should not use enemas or take stool softeners, laxatives, mineral oil, or other medications without first consulting with the primary health care provider or nurse-midwife.

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections? Establish a therapeutic relationship. Use specific closed-ended questions. Omit these types of questions because they are highly personal. Apologize for the embarrassment that these questions will cause the client.

Establish a therapeutic relationship. The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned, purposeful communication that focuses on specific content. The remaining options are incorrect and would not lend themselves to eliciting accurate information from the client.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? Enlargement of the breasts Complaints of feeling hot when the room is cool Periods of fetal movement followed by quiet periods Evidence of bleeding, such as in the gums, petechiae, and purpura

Evidence of bleeding, such as in the gums, petechiae, and purpura Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? Increased insulin Decreased insulin Increased caloric intake Decreased protein intake

Increased insulin Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric and protein intake is not affected by diabetes.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. Avoid stimulation. Decrease fluid intake. Expose all of the newborn's skin. Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches. Phototherapy (bili-light or bili-blanket) is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn may have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

Which is the priority nursing action for the client with an ectopic pregnancy? Assessing urine for proteinuria Checking the electrolyte values Monitoring for signs of infection Monitoring the pulse and blood pressure

Monitoring the pulse and blood pressure Nursing care for a client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate and a drop in blood pressure are indicators of shock. Proteinuria may be associated with preeclampsia, and an elevation in temperature is an indicator of infection. Electrolyte values are unrelated to ectopic pregnancy.

The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item? Tea Milk Coffee Orange juice

Orange juice Foods containing ascorbic acid will increase the absorption of iron. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements. Tannin and caffeine in tea decrease iron absorption. Calcium and phosphorus in milk also decrease iron absorption. Coffee binds iron, prevents it from being fully absorbed, and contains caffeine.

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action? Prepare the client for labor induction. Notify the primary health care provider (PHCP). Place the fetal heart monitor on the client in order to do a nonstress test (NST). Provide the client with information regarding warning signs and symptoms of pregnancy and discharge her to home.

Place the fetal heart monitor on the client in order to do a nonstress test (NST). The BPP includes 5 components, one of which is an NST. Each of these components allows the practitioners to assess if the central nervous system is fully functional and that the fetus is not hypoxemic. Four components are included in the ultrasound portion of the profile in addition to an NST: fetal breathing movements, fetal movements, fetal tone, and amniotic fluid index. Each of the 5 components is given a score of either 2 or 0. Zero indicates an abnormal result, and a 2 indicates a normal result. After the ultrasound components, the client's BPP is 8 out of 8 possible points. This indicates fetal well-being, but there is a need to complete the BPP by obtaining an NST. Notifying the PHCP can be eliminated because the BPP result thus far is normal. Labor induction can be eliminated because the client's gestational age is not term and the BPP reveals no abnormalities or the need for induction. To complete a BPP, an NST must be done; therefore, it is inappropriate to send the client home at this point in her care, so eliminate option 4.

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. Plan induction at 35 weeks. Plan amniocentesis at this time. Schedule a biophysical profile immediately. Plan for weekly nonstress tests at 32 weeks. Obtain nutritional counseling with a dietitian.

Plan for weekly nonstress tests at 32 weeks. Obtain nutritional counseling with a dietitian. Gestational diabetes can result in delayed lung maturity and complications, and carrying the baby until full term is the goal. The nurse should discuss nonstress testing procedures, the plan for nutritional counseling, and the plan for delivery. Amniocentesis is not indicated at this time. Biophysical profile is done at 32 to 36 weeks' gestation.

The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy? Iron supplements should be taken throughout the pregnancy. Calcium intake should be increased for the duration of the pregnancy. Pregnancy greatly increases the risk of malnourishment for the mother. The maternal diet significantly influences fetal growth and development.

Pregnancy greatly increases the risk of malnourishment for the mother. Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Intake of dietary iron is usually insufficient for most pregnant women, and iron supplements are routinely encouraged. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Good nutrition during pregnancy significantly and positively influences fetal growth and development.

The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources for which primary reason? Reduce excessive maternal stress and fatigue. Help the mother prepare for labor and delivery. Avoid exposure to potential pathogens and resulting infections. Prepare the 18-month-old child for maternal separation during hospitalization.

Reduce excessive maternal stress and fatigue. A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The use of resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. These resources are not intended to minimize potential risk of maternal infection or prepare the client and family for the subsequent labor, delivery, and hospitalization.

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? Restrict food and fluids. Reduce external stimuli. Monitor blood glucose levels. Maintain the client in a supine position.

Reduce external stimuli. The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the primary health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? Urinary output of 20 mL Deep tendon reflexes of 2+ Fetal heart rate of 120 beats/minute Respiratory rate of 10 breaths/minute

Respiratory rate of 10 breaths/minute Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the health care provider needs to be notified and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus.

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise should the nurse instruct the client to engage in? Swimming Water skiing Downhill skiing Aerobic exercising

Swimming Non-weight-bearing exercises are preferable to weight-bearing exercises. Non-weight-bearing exercise, such as swimming, is allowed during pregnancy. Competitive or high-risk sports, such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, aerobic exercise, and gymnastics, should be avoided. Other exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided.

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? Urinary output has increased. Dependent edema has resolved. Blood pressure reading is at the prenatal baseline. The client complains of a headache and blurred vision.

The client complains of a headache and blurred vision. If the client complains of a headache and blurred vision, the PHCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply. Vaginal bleeding Excessive fetal activity Excessive nausea and vomiting Larger-than-normal uterus for gestational age Elevated levels of human chorionic gonadotropin (hCG)

Vaginal bleeding Excessive nausea and vomiting Larger-than-normal uterus for gestational age Elevated levels of human chorionic gonadotropin (hCG) The most common findings of gestational trophoblastic disease (hydatidiform mole) include vaginal bleeding, excessive nausea and vomiting, larger-than-normal uterus for gestational age, elevated levels of hCG, failure to detect fetal heart activity even with sensitive instruments, and early development of gestational

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. The nurse should tell the client that which exercise is safest? Walking Scuba diving Low-impact gymnastics Bicycling with the legs in the air

Walking Non-weight-bearing exercises are preferable to weight-bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non-weight-bearing exercises such as walking or swimming are allowed

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the primary health care provider (PHCP). The nurse should tell the woman to call the PHCP if which occurs? Urine test is negative for protein. Fetal movements are more than 4 per hour. Weight increases by more than 1 pound in a week. The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.

Weight increases by more than 1 pound in a week. The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (3 or fewer movements per hour) may indicate fetal compromise and should be reported.