Pregnancy- Uncomplicated EVOLVE
Physical assessment of a client in active labor reveals that the cervix is dilated 3 to 4 cm and 50% effaced, the fetus is in the right sacrum anterior (RSA) position, and contractions are 5 minutes apart. Where should the nurse place the stethoscope to best locate the fetal heart tones?
Correct 1. A When the fetus's back is on the right side of the mother and the fetal sacrum is in the lower portion of the fundus, the fetus is in the right sacrum anterior (RSA) position and the fetal heart can be heard in the right upper quadrant. Location b is appropriate when the fetus is in the right occipital posterior (ROP) position. Location c is appropriate when the fetus is in the left sacrum anterior (LSA) position. Location d is appropriate when the fetus is in the left occipital anterior (LOA) position.
A laboring client expresses concern about the effect that an intravenous analgesic may have on her fetus. What is the best response by the nurse to reassure the client?
1 "I'll dilute the medication so it won't have an immediate impact on the baby." 2 "I'll just give a half-dose of the medication while the uterus is in its relaxed phase." Correct3 "It will be administered during a contraction, when the uterine blood vessels are constricted." 4 "It will be administered in the proximal port of your IV so that you have immediate pain relief." Giving the medication during a contraction, when the uterine vessels are constricted, keeps the medication within the maternal vascular system for several seconds and decreases the impact on the fetus. The other options are incorrect because none of these responses involves administration during a contraction.
At 40 weeks' gestation a client is admitted to the birthing unit in early labor. She asks the nurse, "Why do you want me to lie on my side?" Which response by the nurse explains the primary purpose of the side-lying position during labor?
1 "Lying on the side prevents fetal hyperactivity." 2 "It makes it less likely that you'll have nausea and vomiting." 3 "Lying on the side encourages the presenting part to descend." Correct4 "It enhances blood flow to the uterus and makes contractions easier." In the side-lying position, the gravid uterus does not impede venous return; cardiac output increases, leading to improved uterine perfusion, uterine contractions, and fetal oxygenation. Lying on the side does not affect fetal activity. This position will not ease nausea and vomiting; nausea and vomiting may occur as labor progresses toward the second stage. Walking or squatting will best bring about descent of the presenting part.
Which physiologic alteration does the nurse expect in a client's hematologic system during the second trimester of pregnancy?
1 An increase in hematocrit Correct2 An increase in blood volume 3 A decrease in sedimentation rate 4 A decrease in white blood cells The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks' gestation. The hematocrit decreases as a result of hemodilution. The sedimentation rate increases because of a decrease in plasma proteins. White blood cells count remains stable during the antepartum period.
The nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client?
1 Sims position to facilitate examination Correct2 Semi-Fowler position to avoid hypotension 3 Lithotomy position to enhance visualization 4 Trendelenburg position to prevent cervical pressure The semi-Fowler position prevents supine hypotension and is recommended for both safety and comfort. The Sims position makes monitoring difficult. The lithotomy position is contraindicated for a CST because a vaginal examination is not necessary. The Trendelenburg position is used for shock or a prolapsed cord, not for a CST.
While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?
Correct1 G5 T1 P1 A2 L2 2 G4 T1 P1 A2 L2 3 G4 T2 P0 A0 L2 4 G5 T2 P1 A1 L2 The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions.
After performing Leopold maneuvers on a laboring client, the nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones?
1 Above the umbilicus in the midline 2 Above the umbilicus on the left side Correct3 Below the umbilicus on the right side 4 Below the umbilicus near the left groin Fetal heart tones are best auscultated through the fetal back. In this case the presenting part is in the right occiput posterior position; the back is below the umbilicus and on the right side. Above the umbilicus in the midline is the placement that should be used when the fetus is lying in the midline in a breech position. Placement above the umbilicus on the left side is appropriate when the fetus is in the left sacrum anterior position. Placement below the umbilicus near the left groin is appropriate when the fetus is in the left occiput anterior or left occiput posterior position.
While experiencing contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse's priority intervention be at this time?
1 Assess the fetal heart rate for change. Correct2 Inspect the client's perineum for bulging. 3 Determine when the client's labor began. 4 Verify whether the membranes have ruptured. All signs indicate impending birth; the perineum should be inspected for the appearance of caput. Assessment of fetal status is important; however, the nurse must first determine whether birth is imminent. Determining when the client's labor began and verifying whether the membranes have ruptured are important, but neither addresses the client's complaint.
The nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?
1 At the level of the umbilicus 2 One fingerbreadth above the umbilicus 3 Above and to the right of the umbilicus Correct4 One or two fingerbreadths below the umbilicus The fundus tends to stay at or slightly above the umbilicus for about 24 hours, then decreases in height by about one fingerbreadth per day. The location of the uterus during the first 24 hours postpartum is at one fingerbreadth above the umbilicus. Location of the fundus above and to the right of the umbilicus indicates that the client's bladder is distended and the client should void; this is more likely to occur during the first postpartum day.
After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time?
1 Elevating the client's legs Correct2 Massaging the client's fundus 3 Increasing the client's oxytocin drip rate 4 Examining the client's perineum for bleeding Gentle massage stimulates muscle fibers, resulting in firming the tone of the fundus; it also helps expel any clots that may be interfering with contraction of the fundus. Elevating the client's legs will increase return of blood from the extremities but will not improve the tone of the client's fundus. Increasing the client's oxytocin drip rate will be done if uterine massage is ineffective. Examining the client's perineum for bleeding should not be the first action at this time; gentle massage to contract the fundus is the priority.
A nurse is assessing a primigravida who was admitted in early labor after her membranes have ruptured. She is at 41 weeks' gestation. Her contractions are irregular, and her cervix is dilated 3 cm. The fetal head is at station 0, and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?
1 Encourage her to watch television. Correct2 Take a walk around the unit with her. 3 Ask her to maintain a left-lateral position. 4 Promote the patterned, paced breathing technique. Walking may increase the frequency and intensity of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left-lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?
1 Small tears 2 Greenish-yellow amniotic fluid Correct3 Enlarging area of caput with each contraction 4 An increasing amount of amniotic fluid with each contraction The client should be pushing with each contraction; with the head at +3 station, each push will bring more of the caput into view at the vaginal opening. It is too early for the perineum to be stretched to the point of tearing; if this should occur later, an episiotomy may be performed. Meconium is discoloring the amniotic fluid; it is an unexpected finding that may indicate that the fetus is at risk. There is a decreased, not an increased, amount of amniotic fluid at the end of labor
