Maternal/Child - Antepartum PassPoint
When determining maternal and fetal well-being, which data collection finding is most important? presence of Braxton Hicks contractions signs of orthostatic hypotension fetal heart rate and activity the mother's acceptance of the growing fetus
fetal heart rate and activity Explanation: Assessment data such as the fetal heart rate and fetal activity are most important for determining maternal and fetal well-being. Orthostatic hypotension doesn't occur until late in the pregnancy and is easily correctable. The mother's acceptance of the growing fetus is important, but is a lower priority. Braxton Hicks contractions are normal findings that occur soon after the fourth month of pregnancy. They aren't an important indicator of fetal or maternal well-being.
A client who has sickle cell anemia is 24 weeks' pregnant. When discussing the plan of care, which factors should the nurse identify as potential triggers for a sickle cell crisis during pregnancy? Select all that apply. dehydration tachycardia hypertension stress sedative use
stress dehydration Explanation: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia are not known to precipitate a sickle cell crisis.
A client at 28 weeks' gestation presents to the emergency department with contractions. Following admission and hydration, the health care provider writes an order for the nurse to give 12 mg of betamethasone I.M. The nurse recognizes this medication is given for which action? to prevent infection to promote fetal lung maturity to enhance fetal growth to slow contractions
to promote fetal lung maturity Explanation: Betamethasone is given to promote fetal lung maturity by enhancing the production of surface-active lipoproteins. It has no effect on contractions, fetal growth, or infection.
A pregnant client is prescribed an iron supplement. Which point should the nurse include when teaching the client about taking the supplement? Eat a diet rich in vitamin C to promote iron absorption. Avoid taking the supplement at bedtime to prevent GI upset. Take the supplement with bran, milk, or eggs to increase absorption of the supplement. Avoid taking the supplement on an empty stomach.
Eat a diet rich in vitamin C to promote iron absorption. Explanation: The nurse should teach the client that iron absorption is enhanced by a diet rich in vitamin C. Bran, milk, eggs, coffee, tea, and foods containing oxalate, such as spinach and Swiss chard, inhibit iron absorption when consumed at the same time. Iron supplements are best absorbed on an empty stomach; however, if taking the supplement on an empty stomach causes GI distress, the client may take it just before bedtime to lessen discomfort.
A client in the first trimester of pregnancy reports experiencing nausea every morning and asks about medicine to prevent it. Which response from the nurse would be most helpful? "You'll probably have a lot less nausea in just a few weeks." "I'll ask the health care provider if you can have something prescribed to help." "Let's talk about some methods to control nausea without medication." "You shouldn't take medication during pregnancy, especially during the early weeks."
"Let's talk about some methods to control nausea without medication." Explanation: The nurse should offer to tell the client about nonpharmacologic methods to control nausea. This response gives concrete help to the client without involving drug therapy. Pregnant clients generally should not take medications at any time during pregnancy, and they typically experience nausea relief later in the pregnancy. Drug therapy is inappropriate unless the nausea is detrimental to the client's health.
A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, "I haven't been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me." Which response by the nurse is best? "You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you." "That's fine; you can see whichever health care professional you prefer." "You really need to come to each scheduled appointment here; missing appointments could be harmful." "Don't you want to continue to be cared for by your clinic health care provider?"
"You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you." Explanation: Missing prenatal examinations places the mother and baby at risk for complications. The nurse should encourage the client to attend her health care provider appointments and to discuss her desire to seek care from a homeopathic specialist. By exploring the client's visits to the specialist, the health care provider may be able to incorporate aspects of homeopathy into the client's care plan. The nurse should not encourage the client to see whichever health care provider she prefers. Options 3 and 4 are confrontational.
A client, 7 months pregnant, is receiving the tocolytic agent terbutaline, 17.5 mcg/minute intravenous (I.V.), to halt uterine contractions. She also takes prednisone, 5 mg by mouth twice per day, to control asthma. To detect an adverse interaction between these drugs, what should the nurse monitor this client for? Pulmonary edema Hypertensive crisis Increased uterine contractions Asthma exacerbation
Pulmonary edema Explanation: When administered concomitantly with prednisone or another corticosteroid, terbutaline may cause pulmonary edema. Concomitant administration of a corticosteroid and terbutaline doesn't cause increased uterine contractions, asthma exacerbation, or hypertensive crisis.
During her fourth clinic visit, a client who is 5 months pregnant tells the health care provider she was exposed to rubella during the past week and asks whether she can be immunized now. How would the nurse expect the health care provider to respond? "No, because the vaccine can be given only during the first trimester." "No, because the live viral vaccine is contraindicated during pregnancy." "Yes, and you should consider pregnancy termination because rubella has teratogenic effects." "Yes, I will order the rubella immunization for you."
"No, because the live viral vaccine is contraindicated during pregnancy." Explanation: Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus, which can have teratogenic effects on the fetus. Needing a health care provider's order is not a valid reason for withholding an immunization. Recommending pregnancy termination forces the nurse's viewpoint on the client rather than allowing the client to decide for herself. Exposure to rubella virus may have teratogenic effects if the client is exposed during the first trimester.
A pregnant client concerned about gaining weight during pregnancy questions the nurse about dietary intake. Which response by the nurse is best? "Weight gain is expected, so just enjoy eating for two while you can." "Hasn't your health care provider told you about weight gain during pregnancy?" "Here are pamphlets about a variety of diets; you can choose the one that looks best to you." "I'll ask the dietitian to speak with you about normal weight gain during pregnancy."
"I'll ask the dietitian to speak with you about normal weight gain during pregnancy." Explanation: The nurse should respond by telling the client that she'll ask a dietitian to speak to her about normal weight gain during pregnancy. Option 1 is inappropriate and encourages excessive weight gain. Option 2 is confrontational. Asking the client to choose a diet is inappropriate; the client may choose a diet that is not nutritionally sound during pregnancy.
A pregnant client is concerned about lack of fetal movement. Which response by the nurse would be most therapeutic? "You need to start taking additional prenatal vitamins." "Try taking a warm bath to facilitate fetal movement." "Eat foods that contain a high sugar content to stimulate the fetus." "Lie down once a day and count the number of fetal movements for 15 to 30 minutes."
"Lie down once a day and count the number of fetal movements for 15 to 30 minutes." Explanation: Instructing the client to lie down once during the day will allow the client to concentrate on detecting fetal movement, making it easier to accomplish. The ability to feel fetal movement is reassuring and comforting to the the pregnant client. The pregnant client who is up and actively walking around tends to soothe the fetus, resulting in sleep promotion. Instructing the client to take an additional prenatal vitamins is beyond the nurse's scope of practice and is not recommended because vitamins can be toxic. Taking a warm bath is likely to soothe and relax the fetus. There is also a risk for hyperthermia if the water is too warm or the client is immersed too long. Eating additional sugary foods is not recommended because some pregnant clients are more susceptible to cavities. The additional sugar intake is not associated with stimulating fetal activity.
A primigravida client in the tenth week of pregnancy calls the clinic to report experiencing slight vaginal bleeding. Which response by the nurse would be best? "Continue your normal activities and increase your fluid intake." "Lie down on your left side and call again if the bleeding worsens." "Avoid sexual intercourse for the next 2 weeks." "Save any perineal pads, clots, and tissue and come to the clinic right away."
"Save any perineal pads, clots, and tissue and come to the clinic right away." Explanation: Vaginal bleeding, a sign of threatened abortion, warrants immediate attention. Saving perineal pads and any matter passed vaginally will make evaluation more reliable. The left lateral position is important during the last trimester, when the possibility of supine hypotension syndrome caused by vena cava compression exists. Sexual activity is not usually implicated in spontaneous abortion. Telling the client to continue normal activities and increase fluid intake fails to address the client's immediate need to see a health care provider.
A 30-year-old primiparous client at 34 weeks' gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they're permanent. What is the best response by the nurse? "These streaks are called linea nigra; they'll fade after childbirth." "These streaks are called nevi; they'll fade after the postpartum period." "These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after delivery." "These streaks are called hemangiomas; they're permanent changes resulting from pregnancy."
"These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after delivery." Explanation: The client's weight gain and enlarging uterus, combined with the action of adrenocorticosteroids, lead to stretching of the underlying connective tissue of the skin, creating striae gravidarum in the second and third trimesters. Better known as stretch marks, these streaks commonly develop in skin covering the breasts, abdomen, buttocks, and thighs. After delivery, they typically grow lighter. Linea nigra is a dark line that extends from the umbilicus or above to the mons pubis. In the primigravid client, this line develops at approximately the third month of pregnancy. In the multigravid client, linea nigra typically appears before the third month. Tiny bright hemangiomas may occur during pregnancy as a result of estrogen release. They're called vascular spiders because of the branching pattern that extends from each spot. They typically appear on the neck, thorax, face, and arms. Nevi are circumscribed, benign proliferations of pigment-producing cells in the skin.
A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. How does the nurse correctly interpret this finding? The fetus isn't in distress at this time. The client should repeat the test in 24 hours. The client should repeat the test in 1 week. The fetus should be delivered within 24 hours.
The fetus isn't in distress at this time. Explanation: The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.
A pregnant client at 26 weeks' gestation undergoes a glucose tolerance test. The nurse identifies the need for further action based on which results? a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test a 3-hour glucose level of 130 mg/dL (7.22 mmol/L) during a 3-hour glucose tolerance test a 2-hour glucose level of 150 mg/dL (8.32 mmol/L) during a 3-hour glucose tolerance test a glucose level of 120 mg/dL (6.67 mmol/L) during a 1-hour glucose tolerance test
a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test Explanation: Gestational diabetes is diagnosed when a 3-hour glucose tolerance test has a 1-hour glucose level of 140 mg/dL (7.78 mmol/L) or greater. Other diagnostic test indications of gestational diabetes include a 2-hour glucose level 165 mg/dL (9.16 mmol/L) during a 3-hour glucose tolerance test; a 1-hour glucose test greater than 140 mg/dL (7.78 mmol/L) ; a 3-hour glucose tolerance test with a 2-hour glucose level of 165 mg/dL (9.16 mmol/L) or greater; or a 3-hour glucose tolerance test with a 3-hour glucose level of 145 mg/dL (8.06 mmol/L) or greater.
A client in the 24th week of pregnancy is exhibiting signs and symptoms of preeclampsia. The nurse would be alert for which finding indicating that the client has developed eclampsia? headaches seizures blurred vision weight gain
seizures Explanation: The primary difference between preeclampsia and eclampsia is the occurrence of seizures, which occur when the client develops eclampsia. Headaches, blurred vision, weight gain, increased blood pressure, and edema of the hands and feet are all indicative of preeclampsia.
The nurse educator is discussing signs of pregnancy with newly hired nurses. Which findings would the educator include to be considered positive signs of pregnancy? Select all that apply. fetal heartbeat and fetal movement on palpation fatigue and skin changes quickening and breast enlargement visualization of the gestational sac abdominal enlargement and Braxton Hicks contractions
visualization of the gestational sac fetal heartbeat and fetal movement on palpation Explanation: Visualization of the gestational sac, fetal heartbeat, and fetal movement on palpation are considered positive signs of pregnancy because they cannot be caused by any other condition. Fatigue can be caused by chronic illness or anemia. Skin changes can result from cardiopulmonary disorders, estrogen-progesterone hormonal contraceptives, obesity, or a pelvic tumor. Excessive flatus or increased peristalsis can cause the perception of quickening. Breast changes can be related to hyperprolactinemia induced by tranquilizers, infection, prolactin-secreting pituitary tumor, pseudocyesis, or premenstrual syndrome. Abdominal enlargement can result from ascites, obesity, or a uterine or pelvic tumor, and the perception of Braxton Hicks contractions can result from hematometra or a uterine tumor.
A client asks how long she and her husband can safely continue sexual activity during pregnancy. Which should the nurse recommend? "Until the end of the third trimester" "As long as you wish, if the pregnancy is normal." "Until the end of the second trimester" "Until the end of the first trimester"
"As long as you wish, if the pregnancy is normal." Explanation: The client and her partner can continue sexual activity throughout a normal pregnancy. If the client develops complications that could lead to preterm labor, she and her partner should consult with a health practitioner for advice on the safety of sexual activity.
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? "No, it can initiate premature uterine contractions." "Yes, it produces no adverse effects." "No, it can lead to increased absorption of fat-soluble vitamins." "No, it can promote sodium retention."
"No, it can initiate premature uterine contractions." Explanation: Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn't promote sodium retention. Castor oil isn't known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.
During a prenatal visit, the nurse measures a client's fundal height at 19 cm. The client asks what does this mean. How should the nurse respond? "This measurement indicates that the fetus has reached approximately 24 weeks." "This measurement indicates that the fetus has reached approximately 19 weeks." "This measurement indicates that the fetus has reached approximately 28 weeks." "This measurement indicates that the fetus has reached approximately 12 weeks."
"This measurement indicates that the fetus has reached approximately 19 weeks." Explanation: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.
A client with preeclampsia is prescribed magnesium sulfate to prevent seizure activity. The nurse is reviewing the results of the client's serum magnesium level and determines that the client's level is therapeutic based on which result? 6.8 mEq/L (3.4 mmol/L) 9.2 mEq/L (4.6 mmol/L) 16 mEq/L (8 mmol/L) 11.5 mEq/L (5.75 mmol/L)
6.8 mEq/L (3.4 mmol/L) Explanation: The therapeutic level of magnesium for clients with preeclampsia ranges from 4 to 8 mEq/L (2 to 4 mmol/L). A serum magnesium level of 8 to 10 mEq/L (4 to 5 mmol/L) may cause the absence of reflexes in the client. Serum levels of 10 to 12 mEq/L (5 to 6 mmol/L) may cause respiratory depression, and a serum level of magnesium greater than 15 mEq/L (7.5 mmol/L) may result in respiratory paralysis.
A nurse is reinforcing education for a client entering the third trimester of pregnancy. The nurse determines that the client understands the education when the client states which symptom will be immediately reported? hemorrhoids blurred vision increased vaginal mucus dyspnea on exertion
blurred vision Explanation: During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they do not require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? Make an appointment because the client needs to be evaluated. Explain that these are expected problems for the latter stages of pregnancy. Arrange for the client to be admitted to the birth center for delivery. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.
Explain that these are expected problems for the latter stages of pregnancy. Explanation: The nurse must distinguish between normal physiologic reports of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes related to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client does not need to be seen or admitted for delivery at this time.
When collecting data on a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). The nurse recognizes which condition makes this client more susceptible to such infections? Electrolyte imbalances Hypoglycemia Decreased insulin needs Glycosuria
Glycosuria Explanation: Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially Candida vaginitis) and UTIs, because the hormonal changes of pregnancy affect vaginal pH and the bladder. Electrolyte imbalances and hypoglycemia aren't associated with vaginal infections or UTIs. Insulin requirements may decrease in early pregnancy; however, as the client's food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise.
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse instructs the unlicensed assistive personnel (UAP) to observe her tray for which food selections? Milk and ice pops Decaffeinated coffee and scrambled eggs Tea and gelatin dessert Apple juice and oatmeal
Tea and gelatin dessert Explanation: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.
The nurse is reviewing signs and symptoms of pregnancy complications that should be reported to the health care provider. The nurse determines that the client has understood the information stating that she will immediately report which signs or symptoms if they occur during pregnancy? Select all that apply. facial swelling blurred vision increased urinary frequency nausea fatigue even after resting
blurred vision facial swelling Explanation: Blurred or double vision or facial swelling may indicate gestational hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy due to increased pressure on the bladder from the uterus. Fatigue even after resting and nausea are common reports during pregnancy.
A pregnant client at term is in early labor. Over the past 12 hours, the client has been experiencing contractions every 10 to 12 minutes and has not progressed. The nurse would anticipate which medication as being prescribed to help stimulate uterine contractions? progesterone estrogen oxytocin fetal cortisol
oxytocin Explanation: Oxytocin is the hormone responsible for stimulating uterine contractions and may be given to clients to induce or augment uterine contractions. Although estrogen has a role in uterine contractions, it is not given to help uterine contractility. Fetal cortisol is believed to slow the production of progesterone by the placenta. Progesterone has a relaxing effect on the uterus.
A client has just been diagnosed with having a hydatidiform mole. When reviewing the client's medical record, what is the most significant risk factor? high socioeconomic status primigravida prior molar gestation age in 20s or 30s
prior molar gestation Explanation: A previous molar gestation increases the risk for developing a subsequent molar gestation by four to five times. Adolescents and clients age 40 years and older are at increased risk for molar pregnancies. Multigravidas, especially those with a prior pregnancy loss, and those with lower socioeconomic status are at an increased risk for this problem.
A client who is 27 weeks' pregnant arrives at the health care provider's office reporting fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. About which condition does the nurse anticipate reinforcing education? pyelonephritis urinary tract infection (UTI) bacterial vaginosis asymptomatic bacteriuria
pyelonephritis Explanation: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. Asymptomatic bacteriuria does not cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness.
A client with painless vaginal bleeding is suspected of having placenta previa. The nurse will assist in preparing the client for which procedure? amniocentesis speculum examination external fetal monitoring ultrasound
ultrasound Explanation: When the client and fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination should not be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring will not detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placental separation.
The nurse is reinforcing education for a client in the first trimester of pregnancy. What statement made by the client demonstrates an understanding of the education? "I should begin drinking 32 ounces of whole milk daily to increase my calcium intake." "I need to eat a lot of liver so that I won't become anemic." "I should limit my activities during the first trimester of pregnancy so that I won't have a miscarriage." "I need to take supplemental folic acid to prevent neural tube defects."
"I need to take supplemental folic acid to prevent neural tube defects." Explanation: The client is correct when stating that folic acid supplementation is important to prevent neural tube defects and thus demonstrates an understanding of the education. Eating an abundance of organ meat is not a healthy option and the client will be taking multivitamins to supplement iron to prevent anemia. The client can safely continue activities done prior to pregnancy within reason. The client is not required to drink 32 ounces of milk per day.
A client is diagnosed with hyperemesis gravidarum after coming to the antepartum unit with persistent vomiting, weight loss, and hypovolemia. While gathering data from the client, which information is most significant? Maternal age older than 35 years Malnutrition Low levels of human chorionic gonadotropin (HCG) Trophoblastic disease
Trophoblastic disease Explanation: Trophoblastic disease is associated with hyperemesis gravidarum. Obesity and maternal age younger than 20 years are risk factors for developing hyperemesis gravidarum. High levels of estrogen and HCG have been associated with hyperemesis.
During an examination, a pregnant client at 32 weeks' gestation becomes dizzy, light-headed, and pale while supine. Which action would the nurse do first? Listen to fetal heart tones. Take the client's blood pressure. Turn the client to the left side. Ask the client to breathe deeply.
Turn the client to the left side. Explanation: As the enlarging uterus increases pressure on the inferior vena cava, it compromises venous return, which can cause dizziness, light-headedness, and pallor when the client is supine. The nurse can relieve these symptoms by turning the client to the left side, which relieves pressure on the vena cava and restores venous return. Although they are valuable evaluations, fetal heart tone and maternal blood pressure measurements are not the cause of the problem. Because deep breathing has no effect on venous return, it cannot relieve the client's symptoms.
During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions? "I'll take iron supplements regularly." "I'll increase my intake of unrefined grains." "I'll decrease my intake of green, leafy vegetables." "I'll limit fluid intake to four 8-oz glasses."
"I'll increase my intake of unrefined grains." Explanation: To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as unrefined grains, fruits, and green, leafy vegetables) and fluids. The use of iron supplements can cause — rather than relieve — constipation.
A pregnant client in her second trimester visits the health care practitioner for a regular prenatal checkup. The nurse weighs the client and compares the client's current and previous weights. The client asks how much weight should she gain during the second trimester per week. How would the nurse respond? "You should gain 1 lb (0.45 kg) per week." "You should gain 2 lb (0.91 kg) per week." "You should gain 0.5 lb (0.23 kg) per week." "You should gain 1.5 lb (0.68 kg) per week."
"You should gain 1 lb (0.45 kg) per week." Explanation: During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A woman with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy.
A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn't know whether she's ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer? "You may want to consider having an abortion." "You need to share these feelings with your partner." "You're feeling ambivalent, which is normal during the first trimester." "You may want to discuss these concerns with a social worker."
"You're feeling ambivalent, which is normal during the first trimester." Explanation: The first trimester is known as the trimester of ambivalence because the client or the couple may experience mixed feelings. During this trimester, resolution of ambivalence is the family's key psychosocial task. Discussing these feelings with a social worker or the client's partner would be inappropriate at this time. (However, if further assessment reveals there is a problem, referral to a social worker and discussion with the partner may be appropriate.) Suggesting that the client consider having an abortion is a leading statement and would be inappropriate.
A client is 33 weeks' pregnant and has had diabetes since age 21. When checking the fasting blood glucose level, which value would indicate the client's disease is controlled? 45 mg/dL (2.5 mmol/L) 136 mg/dL (7.56 mmol/L) 85 mg/dL (4.7 mmol/L) 120 mg/dL (6.67 mmol/L)
85 mg/dL (4.7 mmol/L) Explanation: The recommended fasting blood glucose level in the pregnant client with diabetes is 60 to 95 mg/dL (3.33 to 5.28 mmol/L). A fasting blood glucose level of 45 mg/dL (2.5 mmol/L) is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dL (6.67 mmol/L) is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dL (7.56 mmol/L) in a pregnant client indicates hyperglycemia.
When assessing a client for signs and symptoms of ectopic pregnancy, what is the most common sign or symptom associated with this antepartum complication the nurse would expect to find? Nausea and vomiting Vaginal bleeding Temperature elevation Abdominal pain
Abdominal pain Explanation: Abdominal pain is the most common finding in ectopic pregnancy, occurring in more than 90% of women with this antepartum complication. Temperature elevation, vaginal bleeding, and nausea and vomiting are less commonly associated with ectopic pregnancy.
Which of the following would the nurse expect to find as presumptive signs of pregnancy? Uterine enlargement and Chadwick's sign A positive pregnancy test and a fetal outline Braxton Hicks contractions and Hegar's sign Amenorrhea and quickening
Amenorrhea and quickening Explanation: Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators — for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators such as a fetal outline during an ultrasound confirm pregnancy.
Which statement accurately describes estrogen and progesterone levels during the 16th week of pregnancy? Both estrogen and progesterone levels are rising. The estrogen level is much lower than the progesterone level. Both estrogen and progesterone levels are declining. The estrogen level is much higher than the progesterone level.
Both estrogen and progesterone levels are rising. Explanation: Until the seventh month of pregnancy, both estrogen and progesterone are secreted in progressively greater amounts. Between the seventh and ninth months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio promotes the onset of uterine contractions.
A client treated with terbutaline for preterm labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? Increase activity daily if not fatigued. Report a heart rate greater than 120 beats/minute to the health care provider. Call the health care provider if the fetus moves 10 times in an hour. Take terbutaline every 4 hours, during waking hours only.
Report a heart rate greater than 120 beats/minute to the health care provider. Explanation: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the health care provider for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.
A nurse instructs a pregnant client about the importance of doing frequent Kegel exercises. Kegel exercises are important for which reason? They prepare the mother for pushing by strengthening the abdominal muscles. They help maintain good perineal muscle tone by tightening the pubococcygeus muscle. They minimize leg cramps by strengthening the calf muscles. They promote better breathing by strengthening the diaphragm muscle.
They help maintain good perineal muscle tone by tightening the pubococcygeus muscle. Explanation: Kegel exercises are performed by alternately tightening and releasing perineal muscles to strengthen the pubococcygeus muscle and increase its elasticity. The pubococcygeus muscle supports internal organs, such as the uterus and bladder. Kegel exercises do not affect breathing or muscles of the diaphragm, leg, or abdomen.
A client is in the last trimester of pregnancy. The nurse should instruct her to notify her obstetrician immediately if she notices: hemorrhoids. dyspnea on exertion. increased vaginal mucus. blurred vision.
blurred vision. Explanation: Blurred vision or other visual disturbances, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for the client and fetus. Although hemorrhoids may be a problem during pregnancy, they don't require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.
A client at 15 weeks of gestation comes to the clinic for an amniocentesis. If an abnormal result is found, which characteristics or problems could be identified? Select all that apply. chromosomal defects fetal lung maturity polyhydramnios neural tube defects Sex of the fetus. gestational diabetes
chromosomal defects neural tube defects Sex of the fetus. Explanation: In early pregnancy, amniocentesis can be used to identify chromosomal and neural tube defects and to determine the sex of the fetus. It can also be used to evaluate fetal lung maturity during the last trimester of pregnancy. A blood test performed between 24 and 28 weeks of gestation is used to screen for gestational diabetes. Ultrasound is used to identify polyhydramnios; amniocentesis can be used to treat polyhydramnios by removing excess fluid.
A primigravida client is 16 weeks pregnant. Which client instruction would be most important to reinforce in order to prevent toxoplasmosis? keeping dogs outside having antibody titers routinely drawn washing all vegetables cooking meats thoroughly
cooking meats thoroughly Explanation: Undercooked fresh meats that contain cysts with toxoplasmosis can cause infection. Cats, not dogs, carry toxoplasmosis. Toxoplasmosis is not carried on vegetables. Antibody titers do not prevent toxoplasmosis.
During an initial prenatal visit, a client reports increased clear, watery vaginal drainage. When responding to the client about this report, which statement would be most appropriate? "This is normal during pregnancy. Just be sure to wash daily with soap and water." "You might have an infection. The drainage will have to be cultured." "It's typical, but you need to douche daily to help keep the area clean." "This is highly unusual. You must be seen by a health care provider immediately."
"This is normal during pregnancy. Just be sure to wash daily with soap and water." Explanation: Increased vaginal drainage that is clear and watery is normal during pregnancy. However, changes in vaginal pH place the client at increased risk for yeast infection. The nurse should continue to gather additional data from the client about the nature of the drainage. The client needs additional information about proper perineum care. Douching should be avoided during pregnancy.
The nurse is discussing posture with a client who's 18 weeks pregnant. The clients asks why should she avoid the supine position. How does the nurse respond? "This position promotes pregnancy-induced hypertension (PIH)." "This position impedes blood flow to the fetus." "This position may cause gastroesophageal reflux." "This position may trigger heart palpitations."
"This position impedes blood flow to the fetus." Explanation: After the fourth month of pregnancy, the client should avoid the supine position because it allows the gravid uterus to compress veins, blocking blood flow to the fetus. No evidence suggests that the supine position triggers heart palpitations, causes esophageal reflux, or promotes PIH.
The nurse is assessing a client whose membranes ruptured prematurely 12 hours ago. Which is the nurse's highest priority to evaluate when collecting data on this client? White blood cell (WBC) count Cervical effacement and dilation Frequency and duration of contractions Maternal vital signs and fetal heart rate (FHR)
Maternal vital signs and fetal heart rate (FHR) Explanation: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information.
The nurse is reviewing a client's prenatal history. Which finding would suggest to the nurse that it indicates a genetic risk factor? The client has a child with cystic fibrosis. The client was exposed to rubella at 36 weeks' gestation. The client is 25 years old. The client has a history of preterm labor at 32 weeks' gestation.
The client has a child with cystic fibrosis. Explanation: Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age isn't a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn't correlate with genetic defects.
A client in the fifth month of pregnancy is having a routine clinic visit. When gathering data from the client, the nurse would be alert for which common second trimester condition? mastitis metabolic alkalosis physiologic anemia respiratory acidosis
physiologic anemia Explanation: Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. The result is physiologic anemia. Mastitis is an infection in the breast characterized by a swollen, tender breast and flulike symptoms. This condition is most commonly seen in breast-feeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.
The nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: "Do you have any cats at home?" "Do you have any birds at home?" "Have you recently had a rubeola vaccination?" "Have you ever had osteomyelitis?"
"Do you have any cats at home?" Explanation: TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus, agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.
A pregnant client is brought to the emergency department after being an unrestrained driver in a motor vehicle accident. When questioned about seatbelt use, the client states that she thought a seatbelt would harm her baby. Which response by the nurse is best? "I know that seat belts are uncomfortable." "I can see why you'd think that because the seatbelt comes over the lower abdomen." "The only way to safely secure yourself in a car is to use a seatbelt." "I don't use my seatbelt either."
"The only way to safely secure yourself in a car is to use a seatbelt." Explanation: The nurse should explain that using a seatbelt is necessary to safely secure the client in the car and prevent injury. The nurse should also explain that, when worn properly, seatbelts won't cause harm to the baby. Options 1, 2, and 4 are neglectful because they don't encourage seatbelt use.
A client in the seventh month of pregnancy reports back pain and wants to know what can be done to relieve it. After consulting with the supervising nurse about the client's report, which instruction would the nurse most likely reinforce? "Try using pelvic tilt exercises while avoiding lifting heavy objects." "Let others pick things up for you so you don't have to bend over so much." "You need to lie down more during the day to get off your feet." "Your back pain will go away after the baby is born."
"Try using pelvic tilt exercises while avoiding lifting heavy objects." Explanation: The pelvic tilt exercise, which can be done standing as well as lying down, can greatly relieve back discomfort in pregnant clients. As pregnancy progresses into the last trimester, a "swayback" curvature of the spine typically develops to counterbalance the enlarging fetus. Tilting of the pelvis aligns the spine, decreasing pressure and back discomfort. Laying down more during the day may not be possible or convenient for some clients. Also, the supine position may be uncomfortable for some clients and may cause supine hypotension syndrome from vena caval compression (dizziness on rising and decreased circulation to the fetus). Letting someone else pick up items also may not be realistic for the client's circumstances, and it does not address back pain as effectively as the pelvic tilt. Saying that back pain will go away after the baby is born is dismissive and ignores the client's discomfort.
A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy? Support from her partner Previous health promotion activities Previous experiences with health care facilities Socioeconomic status
Support from her partner Explanation: Many factors can influence the smoothness of a pregnant client's psychosocial transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy, but these aren't the most important factors. Previous health promotion activities are least likely to affect this transition.
