Pregnancy, Labor, Childbirth, Postpartum - Uncomplicated
A client at 30 weeks' gestation visits the clinic for a routine examination. At her last visit she told the nurse that she wanted to diet to avoid losing her figure after the baby's birth, and as a result the nurse provided nutrition counseling. At this visit the client weighs 10 lb (4.5 kg) less than on her previous visit. The nurse suspects that the client is not compliant with the recommended nutritional guidelines for pregnancy. Which complication should the client be monitored for? Ketonemia Hyperglycemia Anorexia nervosa Hyperemesis gravidarum
Ketonemia When protein and carbohydrate intake is inadequate, the body catabolizes fat stores for energy, leading to the production of excess fatty acids. Excess fatty acids produce excess ketones in the blood (ketonemia). Hypoglycemia is more likely to occur because carbohydrate intake probably is low. Anorexia nervosa is a pre-pregnancy disorder. The data do not indicate a history of this problem. The data do not indicate that the client has a history of hyperemesis gravidarum, which begins during the first trimester.
Which finding indicates the development of a complication resulting from bilateral cephalohematomas? Urine output Skin color Glucose level Rooting/sucking reflex
Skin color Cephalohematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice may result. Urine output, glucose level, and the rooting/sucking reflex are not affected by a cephalohematoma.
A laboring client has asked the nurse to help her use a nonpharmacologic strategy for pain management. Name the sensory simulation strategy. Gentle massage of the abdomen Biofeedback-assisted relaxation techniques Application of a heat pack to the lower back Selecting a focal point and beginning breathing techniques
Selecting a focal point and beginning breathing techniques Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.
The nurse is assessing a pregnant client during the third trimester. Which clinical finding is expected in the later stages of pregnancy? Tachycardia Dyspnea at rest Progressive dependent edema Shortness of breath on exertion
Shortness of breath on exertion Shortness of breath on exertion is an expected cardiopulmonary adaptation during pregnancy caused by an increased ventricular rate and elevated diaphragm. Tachycardia, dyspnea at rest, and progressive dependent edema are pathologic signs of impending cardiac decompensation.
A client at 28 weeks' gestation who has gained 13 lb (5.9 kg) tells the nurse in the prenatal clinic that she is glad that she has not gained as much weight as her sister did during her pregnancy. How should the nurse respond? "Do you think you're getting fat?" "Are you trying to watch your figure?" "You have to eat right during pregnancy." "Tell me what you've been eating lately."
"Tell me what you've been eating lately." Before the nurse can determine the adequacy of weight gain, it is necessary to determine the client's current dietary intake. The statement that the client must eat right during pregnancy assumes the client is not eating properly. Asking whether the client feels that she's getting fat or is trying to watch her figure may prevent further exploration of the diet because the client may simply answer yes or no.
The four essential components of labor are passenger, powers, passageway, and position. Passageway refers to the bony pelvis. Which type of pelvis is considered the most favorable for a vaginal delivery? Android Anthropoid Gynecoid Platypelloid
Gynecoid A gynecoid pelvis is considered the most favorable for a vaginal birth because the inlet allows the fetus room to easily pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus would have difficulty passing through this shape of pelvis. The anthropoid pelvis is elongated, with a roomy anterior posterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.
A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. How should the nurse respond? "Your mother needs to be present for the examination." "What's the problem with your mother being present?" "I'm sure that your mother wants to be with you for support." Tell the mother, "I'm sorry, but I need to ask you to stay in the waiting area."
Tell the mother, "I'm sorry, but I need to ask you to stay in the waiting area." In many jurisdictions a minor who is self-supporting and living away from home, providing military service, married, pregnant, or a parent is considered an emancipated minor. The emancipated minor assumes most responsibilities before the age of 18 years. An emancipated minor is entitled to confidentiality in dealings with healthcare providers. Therefore it is appropriate to ask the client's mother to step out of the room.
What should the nurse suggest to a pregnant client that might help overcome first-trimester morning sickness? "Eat protein before bedtime." "Take an antacid before breakfast." "Drink water until the nausea subsides." "Take an over-the-counter herbal remedy."
"Eat protein before bedtime." Nausea and vomiting in early pregnancy can be relieved with a small snack of protein before bedtime to slow digestion. An antacid may affect electrolyte balance, and it will not ease morning sickness. Drinking water until the nausea subsides is contraindicated because both fetus and mother need nourishment. Many medications and herbal remedies in the first trimester are contraindicated because this is the period of organogenesis, and such preparations could have teratogenic effects.
The prenatal nurse palpates the uterus of a client who is at 12 weeks' gestation. The uterus is enlarged as expected. What else does the nurse determine about the uterus? It is just above the symphysis pubis. It is buried deep in the pelvic cavity. It is three fingerbreadths above the symphysis pubis. It is causing noticeable bulging of the abdominal wall.
It is just above the symphysis pubis. At 12 weeks' gestation the enlarging uterus begins to rise out of the pelvis and is palpable just above the symphysis pubis. During the early weeks of gestation the uterus remains in the pelvic cavity. Usually this occurs at about 16 weeks' gestation. The noticeable bulging of the abdominal wall occurs later than 12 weeks' gestation when the fundus rises completely from the pelvis and enters the abdominal cavity.
A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear? Maternity girdle Support stockings Low-heeled shoes Loose-fitting clothing
Low-heeled shoes Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area. Maternity girdles are no longer recommended. Support stockings may be helpful for a woman with varicose veins or ankle edema; however, wearing them does not prevent back pain. Loose-fitting clothing is more comfortable, but has no effect on back pain.
During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? Liver and raisins Cheese and broccoli Eggs and lean meats Whole-wheat breads and cereals
Cheese and broccoli The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content. Although liver and raisins, eggs and lean meats, and whole-wheat breads and cereals are recommended as part of a high-quality nutritional intake, they are inadequate sources of calcium.
Which instruction is most important for the nurse to include when teaching a client about a contraction stress test (CST)? Empty the bladder before the test. Eat nothing for 6 hours after the test. Take the prescribed alprazolam before the test. Be prepared to remain in the hospital for 12 hours after the test.
Empty the bladder before the test. The CST will take 1 to 2 hours, during which time the client is confined to bed. Movement on and off a bedpan should be avoided. There are no food restrictions before or after this test. Alprazolam may interfere with results of the CST because it will sedate the fetus. If the test is explained in language that the client can comprehend, an anxiolytic should not be necessary. The client may go home 1 hour after the test is completed.
A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy? Fetal growth Fluid retention Metabolic alterations Increased blood volume
Fetal growth Weight gain during pregnancy averages 25 to 35 lb (11.3 to 15.9 kg). Of this amount, the fetus accounts for 7 to 8 lb (3.2 to 3.6 kg), or approximately 30%. Fluid retention accounts for 20% to 25% of weight gain. Metabolic alterations do not cause weight gain. Increased blood volume accounts for 12% to 16% of weight gain.
How can the nurse best manage a client's care during the transition phase of labor? Decreasing the fluid intake Helping the client maintain control Administering the prescribed opioid medication Encouraging the client to breathe in simple patterns
Helping the client maintain control The transition phase is the most difficult part of labor, and the client needs encouragement and support to cope. Fluid management does not depend on the stage of labor. An opioid at this time is contraindicated because it will depress the newborn's respiration. The breathing pattern should be complex and should require a high level of concentration to distract the client.
While performing patterned, paced breathing during the transition phase of labor, a client experiences tingling and numbness of the fingertips. What should the nurse do? Tell the client to breathe into a paper bag. Place an oxygen mask over the client's face. Call the primary healthcare provider to report the client's response. Instruct the client to begin taking slow deep breaths.
Tell the client to breathe into a paper bag. A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation. The client's oxygen level is increased; the client needs to increase the carbon dioxide level and decrease the oxygen level. The client should rebreathe her own exhalations first; if alkalosis persists, more intensive treatment may be needed. Carbon dioxide is too dilute in room atmosphere; deep breaths will not resolve the alkalosis.
A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression? Smooth, flat baseline tracings of 135 beats/min Abrupt decreases in fetal heart rate that are unrelated to the contractions Accelerations in the fetal heart rate of 10 beats/min above baseline Decelerations when a contraction begins that return to baseline when the contraction ends
Abrupt decreases in fetal heart rate that are unrelated to the contractions Abrupt decreases in fetal heart rate that are unrelated to the contractions are variable decelerations that indicate cord compression. These are most common during the second stage of labor and are considered benign unless the heart rate does not recover adequately. A flat baseline reading indicates decreased variability and may have many causes, but it is not related to cord compression. Fetal heart rate accelerations are not related to cord compression. Decelerations when a contraction begins that return to baseline when the contraction ends indicate head compression during contractions; they are an expected, benign finding.
The partner of a primigravida who has been in active labor for about 6 hours asks the nurse, "How much longer will this take? She's having a lot of back pain, and she's so uncomfortable." How should the nurse respond? "It shouldn't be much longer now." "Take a short break while I take over." "Let me show you how to apply back pressure." "Everything is progressing nicely, just as expected."
"Let me show you how to apply back pressure." Counterpressure against the sacrum during contractions affords some relief from the discomfort of back pain. It is difficult to predict the duration of labor for any client. Telling the coach to leave is not a response to the situation; the coach should be included in providing comfort to the client. Telling the client that everything is progressing nicely is false reassurance; the data do not indicate that labor is progressing as expected.
A client attending a class in preparation for childbirth states, "I am sick and tired of wearing these same old clothes. I just wish all this would be over and done with." What is the nurse's most therapeutic response? "Most women feel the same way you do at this time." "You sound discouraged. Is there something bothering you?" "Yes, this is the most uncomfortable time during pregnancy." "I understand how you feel. What do you know about labor?"
"Most women feel the same way you do at this time." Near term, most mothers are tired of the pregnant state and anxious for labor to begin; it is helpful for the client who feels this way to know that this is a common reaction. The client has just told the nurse what is bothering her; the response does not encourage the client to discuss her feelings further. Stating that this is the most uncomfortable time during pregnancy does not encourage further verbalization; instead, it closes off communication. Asking the client what she knows about labor narrows the client's verbalization to what the nurse believes is the client's area of concern.
The clinic nurse is reviewing the dietary intake of a 16-year-old client who is 12 weeks pregnant. What is the nurse's most appropriate action in this circumstance? Asking the client, "Do you like soy or regular milk products?" Asking the client, "How many servings of dairy do you generally consume each day?" Telling the client, "You may eat yogurt or dried figs as alternative sources of calcium." Telling the client, "You will need to add at least four servings of calcium-rich foods per day."
Asking the client, "How many servings of dairy do you generally consume each day?" The nursing process begins with assessment. Once the nurse knows the number of servings of calcium-rich foods the client consumes each day, the nutritional teaching plan can be personalized to her needs. The daily required intake of calcium for clients younger than 19 years is 1300 mg. This amount can be obtained from 4 cups of milk or yogurt per day. Because there are sources of calcium other than milk, asking whether the client likes milk is not an appropriate first question. Alternative sources of calcium include cheese, yogurt, figs, kale, sardines, orange juice with added calcium, creamy pesto, and cheese sauce. Because the client's daily calcium intake is not known, the number of servings of calcium to be added is also unknown.
Because of the increased discomfort level during the transition phase of labor, nursing care should be directed toward what? Helping the client maintain control Decreasing the rate of intravenous fluid Administering the prescribed medication Having the client breathe in a uniform pattern
Helping the client maintain control The transition phase is the most difficult phase of labor, and the client needs encouragement and support to cope. Fluids should be increased at this time because of the increase in metabolism. Medication is contraindicated at this point because it may depress the newborn at birth. The breathing pattern should be complex, not uniform, at this time because it requires a high level of concentration that helps distract the client.
During a routine prenatal visit, a client tells the nurse that she often gets muscle weakness and leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem? Hypercalcemia; avoid eating hard cheeses Hypocalcemia; increase her intake of milk Hyperkalemia; consult her healthcare provider Hypokalemia; increase intake of green leafy vegetables
Hypocalcemia; increase her intake of milk The most likely cause is a disturbance in the ratio of calcium to phosphorus, with the amount of serum calcium reduced and the serum phosphorus increased; milk and other dairy products are excellent sources of calcium. Leg cramps are related to hypocalcemia, not to hypercalcemia. An increased potassium level manifests as muscle weakness. A low potassium level is evidenced by fatigue and muscle weakness.
An external monitor is placed on the abdomen of a client admitted in active labor. The nurse notes that during each contraction the fetal heart rate decelerates as the contraction peaks. What is the priority nursing intervention at this time? Help the client into a knee-chest position to help prevent cord compression. Notify the healthcare provider of the possibility of head compression. Monitor the fetal heart rate until it returns to baseline when the contraction ends. Place the client in a semi-Fowler position to prevent compression of the vena cava.
Monitor the fetal heart rate until it returns to baseline when the contraction ends. The fetal heart rate (FHR) is expected to decelerate when the head is compressed during a contraction. If the FHR returns to baseline at the end of the contraction, fetal well-being is indicated. Cord compression during a contraction is common; no intervention is necessary if the FHR returns to baseline by the end of the contraction. Possible head compression does not necessitate further intervention; this is an expected occurrence as long as the FHR returns to baseline at the end of the contraction. The semi-Fowler position will increase pressure on the vena cava, thus decreasing placental perfusion.
A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented? Precipitous vaginal delivery Prolonged transitional phase Primigravida primary delivery Normal spontaneous vaginal delivery
Precipitous vaginal delivery A delivery that takes less than 3 hours is considered precipitous. A multipara usually progresses at the rate of 1.5 cm of dilation per hour and must progress to 10 cm for delivery. The second stage, birth, usually averages approximately 20 minutes. A prolonged transitional phase would indicate that progression from 8 to 10 cm took longer than expected and would require augmentation. Primigravida means "first pregnancy," so this cannot be not possible if the client is multiparous, having delivered before. Although this was a vaginal delivery, it was faster than average.
A client delivered a 7-lb 6-oz (3345 g) female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks if the baby be picked up so she can take a nap. Which behavior is the new mother demonstrating? Taking in Letting go Taking hold Bonding failure
Taking in During the taking-in period the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting-go period is when the mother wants to take control and "mother" the infant. The taking-hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.
The nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect? Bulging perineum Pinkish vaginal discharge Crowning of the fetal head Rectal pressure during contractions
Rectal pressure during contractions Rectal pressure occurs at the beginning of the transition phase of labor when the fetal head starts to press on the rectum during contractions. The perineum bulges when transition is complete and the cervix is fully dilated. Pink vaginal discharge occurs when labor begins, not at the beginning of the transition phase. The fetal head crowns at the end of the second stage, shortly before birth.
The nurse reviews the blood test results of a client at 24 weeks' gestation. Which finding should be reported to the healthcare provider? Platelets: 230,000 mm3 (230 × 109/L) Hemoglobin: 10.8 g/dL (108 mmol/L) Fasting blood glucose: 90 mg/dL (4.2 mmol/L) White blood cell count: 10,000 mm3 (10 × 109/L)
Hemoglobin: 10.8 g/dL (108 mmol/L) The hemoglobin level of a healthy individual is 12 to 16 g/dL (120 to 160 mmol/L). During pregnancy it may decrease as a result of an increased blood volume, especially during the second trimester. The hemodilution is greater than a concomitant increase in RBC production, causing physiological anemia. If the hemoglobin decreases to less than 11 g/dL (110 mmol/L), anemia, probably due to a deficiency of iron or folic acid, is diagnosed. Iron supplementation may need to be increased. The expected platelet level is 150,000 to 400,000 mm3 (150 × 109/L to 400 × 109/L). There should be no significant change in this level throughout pregnancy. The expected fasting blood glucose is 70 to 105 mg/dL (3.9 to 5.8 mmol/L); it begins to rise in the second trimester and peaks in the third trimester.
A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this clinical finding to occur? 8th week of pregnancy 10th week of pregnancy 12th week of pregnancy 18th week of pregnancy
12th week of pregnancy By the 12th week of pregnancy the fetus and placenta have grown, expanding the size of the uterus. The enlarged uterus extends into the abdominal cavity. Between the 8th and 10th weeks of pregnancy, the uterus is still within the pelvic area. At the 18th week of pregnancy, the uterus has already risen out of the pelvis and is extending farther into the abdominal area.
A pregnant woman tells the nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse which foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply. Beef and fish Milk and cheese Chicken and turkey Black and pinto beans Enriched bread and pasta
Black and pinto beans Enriched bread and pasta Legumes contain large amounts of folate, as do enriched grain products. Beef and fish do not contain adequate amounts of folate. Milk and cheese do not contain adequate amounts of folate; nor does fowl.
During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response? "That's fine as long as you include a variety of foods daily." "It's a good idea for you to keep your weight down during your pregnancy." "If you add 340 calories a day to your regular diet, you won't become overweight." "Gain no more than 25 lb (11 kg) so that it'll be easier to lose the weight after the baby is born."
"If you add 340 calories a day to your regular diet, you won't become overweight." Weight reduction is not advised during pregnancy; an additional 340 calories a day during the second trimester is recommended. When the client reaches the third trimester, another 120 calories should be added to her diet. A pregnant woman should not diet during pregnancy. Advising the client to eat a variety of foods provides insufficient information. The client should increase her protein and calorie intake during pregnancy. Dieting during pregnancy is harmful; the fetus may be deprived of essential nutrients. The client should not be limited to a specific weight gain. There is no specific recommendation for the amount of weight a pregnant woman should gain. However, 25 to 30 lb (11 to 16 kg) is the average generally suggested; this figure is based on the recommended caloric intake during pregnancy and the client's pre-pregnancy weight and metabolic rate.
A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm and 100% effaced. What should the nurse say while trying to calm the client? "I'll rub your back—that will help ease your pain." "You'll get a shot when you reach the birthing room." "I'm sure you're in pain, but try to bear with it for the baby's sake." "Medication may interfere with the baby's first breaths; keep breathing."
"Medication may interfere with the baby's first breaths; keep breathing." Analgesia crosses the placental barrier; when birth is imminent, it can cause respiratory depression in the newborn. The client is exhibiting fear and panic; a backrub at this time will not be effective and will probably be rejected. Stating that the client will get a shot when she reaches the birthing room is incorrect and provides false reassurance. Although acknowledging that the client is in pain is an empathic response, an explanation of why medication cannot be given is more appropriate in this situation.
A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy. Which clinical findings may the nurse determine upon assessment? Select all that apply. Amenorrhea Breast changes Urinary frequency Abdominal enlargement Positive urine pregnancy test
Amenorrhea Breast changes Urinary frequency The absence of menstruation (amenorrhea) is a presumptive sign of pregnancy that is recognized at 4 weeks' gestation. Breast changes, related to increased levels of estrogen and progesterone, are a presumptive sign of pregnancy that is recognized at 3 to 4 weeks' gestation. Urinary frequency, related to pressure of the enlarging uterus on the urinary bladder, is a presumptive sign of pregnancy that is recognized at 6 to 12 weeks' gestation. Abdominal enlargement related to the enlarging uterus is a probable sign of pregnancy that is recognized when the enlarging uterus rises out of the pelvis at 14 to 16 weeks' gestation. A positive urine pregnancy test result, indicating an increase in human chorionic gonadotropin, is a probable sign of pregnancy. Sensitive blood tests can detect this hormone within 6 to 12 days of conception, and urine tests can detect it 26 days after conception.
A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the what? Adrenal gland Thyroid gland Anterior pituitary gland Posterior pituitary gland
Anterior pituitary gland Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.
What should the nurse should explain to the newly pregnant primigravida about how and when the fetal heartbeat will first be heard? A fetoscope around 8 weeks A fetoscope at 12 to 14 weeks Electronic Doppler ultrasonography after 17 weeks Electronic Doppler ultrasonography at 10 to 12 weeks
Electronic Doppler ultrasonography at 10 to 12 weeks The fetal heartbeat can be heard on electronic Doppler ultrasound between 10 and 12 weeks' gestation. Around 8 weeks is too early for the heartbeat to be heard with a fetoscope; a fetoscope can pick up the fetal heartbeat accurately around the twentieth week. The fetal heartbeat can be heard at least 5 weeks earlier with the use of electronic Doppler ultrasound.
A client in her second trimester is at the prenatal clinic for a routine visit. While listening to the fetal heart, the nurse hears a heartbeat at the rate of 136 in the right upper quadrant and also at the midline below the umbilicus. What are the sources of these two sounds? Heart tones of two fetuses Maternal and fetal heart tones Funic souffle and fetal heart rate Maternal heart rate with a uterine souffle
Funic souffle and fetal heart rate The funic souffle is the sound of blood rushing through the fetal umbilical cord and is therefore the same rate as the fetal heart rate. Twins will have different heart rates. The maternal heart rate should be much slower than the fetal heart rate. The uterine souffle, caused by blood moving through the maternal side of the placenta, is the same as the mother's heart rate, which should be less than 100.
A primigravid client is admitted to the birthing unit in active labor. The fetus is in a breech presentation. Which physiologic response does the nurse expect during this client's labor? Heavy vaginal bleeding Fetal heart rate irregularities Greenish-tinged amniotic fluid Severe back pain with contractions
Greenish-tinged amniotic fluid Greenish amniotic fluid is common in a breech presentation because the contracting uterus exerts pressure on the fetus's lower colon, forcing the expulsion of meconium. Mild bloody show is expected; a heavier flow is a deviation from the expected response and not a common finding with breech presentations. Fetal heart rate irregularities are not specific to a breech presentation. Severe back pain is more likely to occur when the fetus is in a cephalic presentation and the occiput is in the posterior position.
The nurse is attempting to determine whether a pregnant woman's membranes have ruptured. Which findings support the conclusion that the membranes have ruptured? Select all that apply. The expelled fluid totals 500 mL. The expelled fluid is light yellow. The expelled fluid smells similar to urine. Nitrazine paper turns blue on contact with the fluid. Microscopic examination of the fluid reveals ferning.
Nitrazine paper turns blue on contact with the fluid. Microscopic examination of the fluid reveals ferning. An alkaline fluid will turn Nitrazine paper blue; amniotic fluid is alkaline. Amniotic fluid demonstrates a ferning pattern, which is visible with a microscope, when placed on a slide. It is not the amount of fluid that is observed, but the characteristics of the fluid that are significant. Amniotic fluid should be clear and may contain white specks of vernix. Yellow coloration indicates that the fluid may be urine. Green fluid is indicative of meconium staining, which is a nonreassuring fetal sign. The odor of amniotic fluid is not similar to that of urine. Amniotic fluid has a mild, somewhat fleshy odor.
A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. (16 X 109/L) What is the next nursing action? Checking with the nurse manager to see whether the client may go home Reassessing the client for signs of infection by taking her vital signs Delaying the client's discharge until the practitioner has conducted a complete examination Placing the report in the client's record because this is an expected postpartum finding
Placing the report in the client's record because this is an expected postpartum finding Leukocytosis (15,000 to 20,000/mm3 WBC) (15 to 20 X 109/L) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention because the client is exhibiting an expected postpartum leukocytosis.
A client in active labor is admitted to the birthing room. A vaginal examination reveals the cervix to be dilated to 7 cm. On the basis of this finding, what does the nurse expect the client to exhibit? Nausea and vomiting Bloody and profuse show Inability to control her shaking legs Strong contractions with intervals of several minutes between
Strong contractions with intervals of several minutes between Strong contractions with intervals of several moments between is a description of the contractions that occur during the active portion of the first stage of labor. Nausea and vomiting, profuse bloody show, and inability to control shaking legs all occur in the transition phase of the first stage of labor (8 to 10 cm cervical dilation).
The nurse is caring for a primigravid client during labor. Which physiologic finding does the nurse observe that indicates birth is about to take place? Bloody discharge from the vagina is increasing. The perineum has begun to bulge with each contraction. The client becomes irritable and stops following instructions. Contractions occur more frequently, are stronger, and last longer.
The perineum has begun to bulge with each contraction. The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. An increase in bloody show and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent.