AQ Test 2 questions

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action? 1. Administering oxygen 2. Elevating the head of the bed 3. Drawing blood for a hematocrit level 4. Giving an intramuscular analgesic

1. Administering oxygen Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary healthcare provider's prescription.

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? 1. It is just above the symphysis pubis 2. It is buried deep in the pelvic cavity 3. It is three fingerbreadths above the symphysis pubis. 4. It is causing noticeable bulging of the abdominal wall

1. 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.

100.8° F (38.2° C), chills, and malaise. Which condition does the nurse suspect? 1. Mastitis 2. Engorgement 3. Blocked milk duct 4. Inadequate milk production

1. Mastitis Because of the presence of generalized symptoms, the nurse should suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced.

A client at 34 weeks' gestation is receiving terbutaline subcutaneously. Her contractions increase to every 5 minutes, and her cervix dilates to 4 cm. The tocolytic is discontinued. What is the priority nursing care during this time? 1. Promoting maternal-fetal well-being during labor 2. Reducing the anxiety associated with preterm labor 3. Supporting communication between the client and her partner 4. Assisting the client and her partner with the breathing techniques needed as labor progresses

1. Promoting maternal-fetal well-being during labor Labor is continuing, and the promotion of the well-being of the client and fetus is the priority nursing care during this period. Reducing the anxiety associated with preterm labor, supporting communication between the client and her partner, and assisting the client and her partner with breathing techniques each address one aspect of this client's needs; the priority is maternal/fetal well-being

A client at 28 weeks' gestation visits the clinic for a routine examination. Which finding is of greatest concern to the nurse? 1. Puffy fingers 2. Glycosuria 1+ 3. Proteinuria 1+ 4. Dependent edema

1. Puffy fingers One sign of mild preeclampsia is puffiness of the fingers, eyes, and face. Glycosuria is a common finding in pregnancy; an increased glomerular filtration rate in conjunction with decreased capacity of the tubules to reabsorb glucose may cause spillage of glucose into urine. Minimal proteinuria may occur in a healthy pregnancy; the amount of protein that must be filtered exceeds the ability of the tubules to absorb it, causing small amounts to be lost in the urine. Venous obstruction from the gravid uterus decreases blood flow to the heart; as a result, fluid pools in the lower extremities; dependent edema is expected.

Which prenatal teaching is most applicable for a client who is between 13 and 24 weeks' gestation? 1. Infant care, travel to the hospital, and signs of labor 2. Growth of the fetus, personal hygiene, and nutritional guidance 3. Interventions for nausea and vomiting, urinary frequency, and anticipated care 4. Danger signs of preeclampsia, relaxation breathing techniques, and signs of labor

2. Growth of the fetus, personal hygiene, and nutritional guidance Awareness of the fetus as an individual and the expected changes of pregnancy lead the client to seek information regarding fetal growth, body changes, and nutrition. Information on infant care, travel to the hospital, signs of labor, signs of preeclampsia, and relaxation breathing techniques is appropriate in the last trimester. Interventions for nausea and vomiting, urinary frequency, and anticipated care are appropriate for the first trimester.

A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravidarum. She is to be maintained at home with rehydration infusion therapy. What is the priority nursing activity for the home health nurse? 1. Determining fetal well-being 2. Monitoring for signs of infection 3. Monitoring the client for signs of electrolyte imbalances 4. Teaching about changes in nutritional needs during pregnancy

3. Monitoring the client for signs of electrolyte imbalances Rehydration fluids contain only saline and dextrose; if the client continues to vomit, she will lose electrolytes. Monitoring the fetus is not the priority at this time. Although there is a danger of infection when an intravenous line is in place, monitoring for it is not the priority. Teaching about nutritional needs is a nontherapeutic nursing action while the client is still vomiting.

*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. 1. Beef and fish 2. Milk and cheese 3. Chicken and turkey 4. Black and pinto beans 5. Enriched bread and pasta

4. Black and pinto beans 5. 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.

A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? 1. Hydatidiform mole 2. Vena cava syndrome 3. Marginal placenta previa 4. Complete abruptio placentae

4. Complete abruptio placentae Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.

*During the initial prenatal visit of a woman at 23 weeks' gestation, the nurse discovers that she has a history of pica. What is the most appropriate nursing action? 1. Seeking a psychology referral 2. Explaining the danger this poses to the fetus 3. Obtaining a prescription for an iron supplement 4. Determining whether the diet is nutritionally adequate

4. Determining whether the diet is nutritionally adequate The primary concern for a pregnant women who practices pica is that her diet is nutritionally inadequate. Nutritional guidance may be necessary, depending on the findings of this assessment. Pica does not indicate a psychologic/emotional disturbance; frequently it is influenced by the client's culture. If a substance is not toxic to the mother, it is generally not fetotoxic. Iron is routinely prescribed during pregnancy; this does not specifically address the practice of pica.

*A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage this new mother to do? Select all that apply. 1. Apply cool packs to her breasts to reduce the discomfort. 2. Take the analgesic medication prescribed to limit the discomfort. 3. Remove the infant from the breast for a few days to rest the nipples. 4. Never expose the nipples to air; only wear a tight-fitting brassiere. 5. Assume a different position when breastfeeding to adjust the infant's sucking.

1. Apply cool packs to her breasts to reduce the discomfort. 2. Take the analgesic medication prescribed to limit the discomfort. 5. Assume a different position when breastfeeding to adjust the infant's sucking. Applying cool packs to the breasts to reduce the discomfort may provide relief after a feeding. Analgesics may eventually be necessary. Altering the breastfeeding position may ensure that the entire nipple and as much of the areola as possible are in the infant's mouth. When the infant is latched on the nipple correctly and a finger is used to release suction at the end of a feeding, trauma to the nipple is reduced. Soreness is common; it usually occurs at the beginning of a feeding and is temporary, lasting until the nipples become accustomed to the infant's sucking. Nursing mothers should be encouraged to expose their nipples to air several times a day. Discontinuing feeding for several days will result in engorgement, which will increase the discomfort.

*What is the optimal method for the nurse to use to assess blood loss in a client with placenta previa? 1. Count or weigh perineal pads 2. Monitor pulse and blood pressure 3. Check hemoglobin and hematocrit values 4. Measure or estimate the height of the fundus

1. Count or weigh perineal pads An accurate measurement of the amount of blood loss may be obtained by counting or weighing perineal pads. The vital signs will reflect the effects of the blood loss rather than the amount. Laboratory results demonstrate the effects of the blood loss rather than the amount. The fundus may be higher than expected, because the low-lying placenta prevents the descent of the fetus into the pelvis, but the height cannot be used to estimate blood loss.

A pregnant client experiences an episode of painless vaginal bleeding during the last trimester. What does the nurse suspect is the cause of this bleeding? 1. Placenta previa 2. Abruptio placentae 3. Frequent sexual intercourse 4. Excessive alcohol ingestio

1. Placenta previa As the lower uterus contracts and dilates, the edge of the low-lying placenta separates from the walls of the uterus, thereby opening placental sinuses and allowing blood to escape. Abruptio placentae is usually accompanied by intense pain. Frequent sexual intercourse is probably not the cause unless placenta previa is present. Alcohol ingestion does not cause painless vaginal bleeding.

*A lactating woman who reports a loss of interest in daily activities, loss of appetite, and sleeplessness is diagnosed with depression. What would be the drug of choice for this client if she wishes to continue breast-feeding? 1. Sertraline 2. Fluoxetine 3. Sumatriptan 4. Bromocriptine

1. Sertraline Sertraline is the drug of choice for lactating woman with depression because it does not cause any effects on breast-feeding infants. Fluoxetine should be taken with caution because it may cause adverse effects on the infant at high dosages. Sumatriptan is the drug of choice for lactating woman suffering from migraines because it does not adversely affect to the fetus. Bromocriptine is contraindicated in lactating woman.

*A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. What should the nurse include? Select all that apply. 1. Sleep needs increase 2. Urinary frequency 3. Body temperature decreases 4. Calcium requirements remain the same 5. The need for carbohydrates decreases

1. Sleep needs increase 2. Urinary frequency 4. Calcium requirements remain the same Estrogen increases the secretion of corticosteroids, which decrease the basal metabolic rate, resulting in fatigue. Sodium is retained. Urinary frequency occurs. During the first trimester approximately 1000 mg of calcium is needed each day. There is no longer a recommendation for an increase in daily calcium intake during pregnancy and lactation. The daily recommended intake of 1000 mg for women older than 19 years and 1300 mg for women younger than 19 years is adequate for fetal bone and tooth development. Body temperature increases because of the increased metabolism related to the growth of the fetus. Carbohydrate needs increase because the secretion of insulin by the pancreas is increased; however, insulin is destroyed rapidly by the placenta. The stress of pregnancy may precipitate gestational diabetes.

A nurse is teaching breast-feeding to a newly delivered client. Which statement by the client indicates the need for further instruction? 1. "I'll try to empty my breasts at each feeding." 2. "I'll alternate between breasts to start feedings." 3. "I need to wash my breasts with soapy water before I breast-feed." 4. "I need to stroke my baby's cheek gently when I'm ready to breast-feed."

3. "I need to wash my breasts with soapy water before I breast-feed." Soap irritates, cracks, and dries breasts and nipples, making it painful for the mother when the baby sucks; it also increases the risk for mastitis. The client should empty the breasts at each feeding to keep milk flowing. Alternating between breasts to start feedings is a permissible and often-used technique of breast-feeding. Gently stroking the baby's cheek elicits the rooting reflex; the infant's head turns toward and touches the mother's breast.

A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is reviewing signs and symptoms that should be reported to the primary healthcare provider with the mother. Which signs and symptoms require further evaluation by the primary healthcare provider? Select all that apply. 1. decreased urine output 2. blurred vision with spots 3. urinary frequency without dysuria 4. heartburn with eating a fatty meal 5. contractions that are regular and 5 minutes apart 6. shortness of breath after a flight of stairs

1. decreased urine output 2. blurred vision with spots 5. contractions that are regular and 5 minutes apart Decreased urine output, blurred vision, and severe headache may occur with pregnancy-associated hypertension. Contractions that become regular are associated with the onset of labor. Preparatory (Braxton Hicks) contractions ease when the client walks. Urinary frequency occurs in the first trimester and again in the third trimester as the uterus settles back into the pelvis. The weight of the uterus may delay emptying of the stomach and make heartburn a more frequent problem. Shortness of breath would be expected after the client climbs a flight of stairs.

*A client attending the prenatal clinic for a follow-up appointment has been diagnosed with mild preeclampsia. How should the nurse instruct the client regarding her fluid and nutritional intake? 1. "Restrict fluid intake." 2. "Stay on a low-salt diet." 3. "Continue the pregnancy diet." 4. "Increase carbohydrate consumption."

3. "Continue the pregnancy diet." If the client with mild preeclampsia is following the recommended pregnancy diet, she should continue it. Fluids should not be restricted during pregnancy. Salt restriction may activate an angiotensin response, which could cause an increase in blood pressure; moderate salt intake is recommended. There is no reason for the client with mild preeclampsia to increase her intake of carbohydrates.

During a physical examination in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. Which sign should the nurse document in the client's clinical record? 1. Hegar 2. Goodell 3. Chadwick 4. Braxton Hicks

3. Chadwick A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton Hicks contractions, can be felt through the abdominal wall.

A client visits the prenatal clinic for the first time. The client tells the nurse that her last menstrual period began June 10. The nurse uses the Nägele rule to calculate the EDB. What is the EDB? 1. April 7 2. March 7 3. April 10 4. March 17

4. March 17 The EDB is March 17. Using the Nägele rule, subtract 3 months and add 1 year and 7 days to the first day of the last menstrual period. April 7, March 7, and April 10 all represent inaccurate applications of the Nägele rule.

*A client asks about the difference between cow's milk and breast milk. The nurse should respond that cow's milk differs from human milk in that it contains what? 1. Less protein, less calcium, and more carbohydrates 2. More protein, less calcium, and fewer carbohydrates 3. Less protein, more calcium, and more carbohydrates 4. More protein, more calcium, and fewer carbohydrates

4. More protein, more calcium, and fewer carbohydrates Cow's milk contains more protein, more calcium, and fewer carbohydrates. Cow's milk is more difficult to digest because it is meant to meet a calf's, not an infant's, nutritional needs. It is not recommended until after the infant is 1 year old. Formula is preferred if the mother is not breastfeeding.

*A pregnant client with type 1 diabetes is visiting the prenatal clinic for the first time. What is the primary long-term goal for this client? 1. Insulin dosages will decrease 2. Dietary fluctuations will be minimized 3. The blood glucose level will remain stable 4. Pregnancy will end with the birth of a healthy infant

4. Pregnancy will end with the birth of a healthy infant In any prenatal situation, the goal is an optimally healthy mother and newborn, no matter what other factors are involved. Insulin is given as necessary to maintain an acceptable glucose level. Minimizing dietary fluctuations is important, but it is not the priority. Stabilizing the blood glucose level is an ongoing goal, not a long-term goal.

*A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of which month? 1. Fifth month 2. Third month 3. Fourth month 4. Second month

2. Third month Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin, but has usually diminished by the fifth month.

At 32 weeks' gestation a client undergoes an ultrasound examination, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term? 1. Sharp abdominal pain 2. Painless vaginal bleeding 3. Increased lower back pain 4. Early rupture of membranes

2. Painless vaginal bleeding Because the process of effacement occurs in the latter part of pregnancy, placental separation from the uterus may occur, causing painless bleeding. There is pain with premature separation of a normally implanted placenta (abruptio placentae). Lower back pain is not associated with placenta previa. Rupture of membranes usually does not occur before the placenta starts to separate.

The nurse is teaching participants in a prenatal class regarding breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which response is most appropriate? 1. "Breastfed infants have fewer infections." 2. "Breastfeeding inhibits ovulation in the mother." 3. "Breastfed infants adhere more easily to a feeding schedule." 4. "Breastfeeding provides more protein than cow's milk formula does."

1. "Breastfed infants have fewer infections." Maternal antibodies are transferred from the mother in breast milk, providing protection for a longer time than do antibodies transferred to the fetus by way of the placenta. The neonate is protected by the antibodies. The fetus' own antibody system is immature at birth. Lactating mothers rarely ovulate for the first 9 postpartum weeks; however, they may ovulate at any time after that period; although a breastfed infant adhering more easily to a feeding schedule may be considered an advantage, it is not a primary advantage. Because of the higher carbohydrate content of breast milk, which is digested rapidly, breastfed infants wake more frequently than formula-fed infants. Their feeding demands take more time to regulate than do the formula-fed infant's. Breast milk has 1.1 g protein/100 mL; cow's milk has 3.5 g/100 mL. Whole cow's milk is unsuitable for infants.

*Which statement related to breast-feeding is correct? 1. Protein soluble drugs can enter breast milk. 2. Drugs with a long half-life should be avoided. 3. Mothers should take drugs prior to breast-feeding. 4. Drug usage during lactation is safe because the drugs will not harm the baby

2. Drugs with a long half-life should be avoided. Drugs with a longer half-life stay in the body for a longer time and may enter the breast milk, which can produce unwanted pharmacologic effects in the child. Therefore drugs with a longer half-life should be avoided. Lipid soluble drugs can enter the breast milk. Mothers should take drugs immediately after breast-feeding to reduce the possibility of drugs entering the breast milk. Although the concentration of drugs entering breast milk is very low, drug usage should be minimized during lactation to prevent any unknown harmful effects on the newborn.

*A client at 30 weeks' gestation is being examined in the prenatal clinic. The nurse identifies a respiratory rate of 26 breaths/min, blood pressure of 100/60 mm Hg, and diaphragmatic tenderness. The client also reports increased urinary output. Which of these findings indicates that the client may be experiencing a complication? 1. Urinary output 2. Blood pressure 3. Respiratory rate 4. Diaphragmatic tenderness

3. Respiratory rate The increased respiratory rate is one sign of cardiac decompensation; cardiac output and blood volume peak during the second trimester, and signs and symptoms of cardiac disease become prominent at this time. Oliguria (not increased urine output), accompanied by edema of the face, legs, and fingers, is a sign of cardiac complications. The client's blood pressure is within the expected range for a pregnant woman. Diaphragmatic tenderness is a vague symptom that is not related to heart disease.

A physically active 19-year-old primigravida attends the prenatal clinic for the first time. She asks the nurse whether she may continue playing tennis and riding horses while she is pregnant. How should the nurse reply? 1. "Continue your usual activities as long as you are comfortable." 2. "Horseback riding is acceptable, but only up to the last trimester." 3. "Tennis is good exercise for you, but horseback riding is too strenuous." 4. "Both of these sports have been found to be too strenuous for a pregnant woman."

1. "Continue your usual activities as long as you are comfortable." Any regular activity that was typical before pregnancy may be safely continued in pregnancy if there are no complications such as bleeding, cramps, or pain. It is not necessary to stop riding after the second trimester unless the woman is uncomfortable or it is otherwise contraindicated. A woman used to riding horses may continue doing so—no exercise is too strenuous if it was done consistently before pregnancy—so both tennis and riding are acceptable as long as the woman is accustomed to doing them.

A nurse teaches the warning signs that should be reported throughout pregnancy. Which statement by the client indicates an understanding of the prenatal instructions? 1. "I'll call the clinic if I have abdominal pain." 2. "Mild, irregular contractions mean that my labor is starting." 3. "I need to call the clinic if my ankles start to swell at night." 4. "A whitish vaginal discharge means that I'm getting an infection."

1. "I'll call the clinic if I have abdominal pain." Abdominal pain should be reported immediately, because it may indicate abruptio placentae or the epigastric discomfort of severe preeclampsia. Mild, irregular contractions are preparatory (Braxton Hicks) contractions, which are common and are believed to help prepare the uterus for labor. Swelling of the ankles at night is physiologic edema of pregnancy, caused by pressure of the gravid uterus that impedes venous return; it disappears with elevation of the legs. Leukorrhea occurs during pregnancy as a result of increases in the estrogen and progesterone levels, which cause the vaginal discharge to become more alkaline.

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she is experiencing heartburn after every meal. Which explanation should the nurse provide regarding the cause of the heartburn? 1. "The esophageal sphincter relaxes and allows acid to be regurgitated." 2. "In pregnancy, gastric motility increases, causing a burning sensation." 3. "In pregnancy, gastric pH increases, causing acid to enter the esophagus." 4. "In pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine."

1. "The esophageal sphincter relaxes and allows acid to be regurgitated." Relaxation of the esophageal sphincter, resulting in regurgitation of acid, causes heartburn (pyrosis) during the second half of pregnancy. Delayed emptying of stomach contents because of decreased gastric motility and displacement of the stomach because of uterine enlargement contribute to the problem. Gastric motility is decreased during pregnancy. When gastric pH increases, gastric juices become more alkaline, leaving little or no acid to be regurgitated into the esophagus. The pyloric sphincter does not relax, and acid does not pass into the small intestine.

The nurse is counseling a pregnant client with type 1 diabetes regarding medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy? 1. Insulin 2. Antihypertensives 3. Pancreatic enzymes 4. Estrogenic hormones

1. insulin Usually as pregnancy progresses there are alterations in glucose tolerance and in the metabolism and utilization of insulin. The result is an increased need for exogenous insulin. Antihypertensives are administered only to clients with severe hypertensive preeclampsia. Pancreatic enzymes or hormones other than insulin are not taken by pregnant women with diabetes. Estrogenic hormones are not administered during pregnancy.

A new mother who has begun breastfeeding asks for assistance removing the baby from her breast. Which instruction is most appropriate for the nurse to provide? 1. "Pinch the baby's nostrils gently to help release the nipple." 2. "Let the baby nurse as long as desired without interruption." 3. "Pull your nipple out of the baby's mouth when the baby falls asleep." 4. "Insert your finger in the corner of the baby's mouth to break the suction."

4. "Insert your finger in the corner of the baby's mouth to break the suction." Inserting a finger into the corner of the baby's mouth is painless and will help prevent damage to the mother's nipple. Pinching the baby's nostrils is somewhat cruel; breaking suction with a finger is less traumatic. The mother may need to remove the baby from the breast before the baby is ready to let go, and the mother should be taught how to do this. Pulling without first breaking the suction may inflict trauma on the nipple.

A nurse teaches the warning signs that should be reported throughout pregnancy. Which statement by the client indicates an understanding of the prenatal instructions? 1. "I'll call the clinic if I have abdominal pain." 2. "Mild, irregular contractions mean that my labor is starting." 3. "I need to call the clinic if my ankles start to swell at night. 4. "A whitish vaginal discharge means that I'm getting an infection."

1. "I'll call the clinic if I have abdominal pain." Abdominal pain should be reported immediately, because it may indicate abruptio placentae or the epigastric discomfort of severe preeclampsia. Mild, irregular contractions are preparatory (Braxton Hicks) contractions, which are common and are believed to help prepare the uterus for labor. Swelling of the ankles at night is physiologic edema of pregnancy, caused by pressure of the gravid uterus that impedes venous return; it disappears with elevation of the legs. Leukorrhea occurs during pregnancy as a result of increases in the estrogen and progesterone levels, which cause the vaginal discharge to become more alkaline.

During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. Which guidance should the nurse provide regarding sleeping position? 1. "Turn from side to side." 2. "Try to sleep on your stomach." 3. "Elevate the head of the bed on blocks." 4. "Place two pillows under your knees for sleep."

1. "Turn from side to side." The side-lying position will relieve back pressure; it also promotes uterine perfusion and fetal oxygenation. At 32 weeks' gestation the abdomen is too distended for the pregnant woman to lie in the prone position. Elevating the head of the bed will not relieve back pressure; it is used to limit gastroesophageal reflux. Lying on the back is contraindicated because it puts pressure on the vena cava, resulting in hypotension and uteroplacental insufficiency. Pillows under the knees are contraindicated because they place pressure on the popliteal area, which compresses the venous circulation, increasing the risk of thrombophlebitis.

A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond? 1. "What activities does your job entail?" 2. "How do you feel about continuing to work?" 3. "Most women work throughout their pregnancies." 4. "Usually women quit work at the start of their third trimester."

1. "What activities does your job entail?" More information is needed before the nurse can give a professional response. Although it is important to ascertain the client's feelings about continuing to work, at this time she is seeking information. Although it is true that most women work throughout their pregnancies, more information is needed before the nurse can respond. It is misinformation to state that usually women quit work at the start of the third trimester.

The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? 1. Hemorrhage 2. Dehydration 3. Hypertension 4. Subinvolution

1. Hemorrhage Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth.

On a routine prenatal visit, what is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? 1. Quickening 2. Palpitations 3. Pedal edema 4. Vaginal spotting

1. Quickening The recognition of fetal movement commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting at this time requires immediate follow-up care.

*A pregnant woman at 6 weeks' gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement. What should the nurse recommend to the client? Select all that apply. 1. Stop taking the supplement immediately. 2. Discuss the use of the supplement with the practitioner. 3. Increase the dosage of the supplement as pregnancy progresses. 4. Ask the pharmacist whether the supplement is safe for use during pregnancy. 5. Discuss the use of any over-the-counter products with the practitioner.

1. Stop taking the supplement immediately. 2. Discuss the use of the supplement with the practitioner. 5. Discuss the use of any over-the-counter products with the practitioner. Stopping the supplement is appropriate until more instructions are received from the practitioner. It is the practitioner's responsibility to counsel the client regarding all prescriptions, over-the-counter medications, and supplements. Continuing or increasing the dose of the supplement is unsafe; it may be detrimental to both the client and the fetus. The nurse may not prescribe medications of any kind, and to do so is functioning outside of the legal definition of nursing practice. It is the practitioner's responsibility, not the pharmacist's, to counsel the client regarding all prescriptions, over-the-counter medications, and supplements.

*A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time? 1. Reduction of anxiety associated with preterm labor 2. Promotion of maternal and fetal well-being during labor 3. Supportive communication with the client and her partner 4. Helping the family cope with the impending preterm birth

2. Promotion of maternal and fetal well-being during labor Labor is continuing, and promotion of the well-being of both client and fetus is the priority nursing care during this period. Reduction of anxiety associated with preterm labor, supportive communication with the client and her partner, and helping the family cope with the impending preterm birth each address just one aspect of this client's needs and must be dealt with in the context of the priority need.

A client at 36 weeks' gestation is admitted to the high-risk unit because she has gained 5 lb (2.3 kg) in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care? 1. Preparing for an imminent cesarean birth 2. Providing a dark, quiet room with minimal stimuli 3. Initiating intravenous (IV) furosemide to promote diuresis 4. Administering calcium gluconate to lower the blood pressure

2. Providing a dark, quiet room with minimal stimuli Increasing cerebral edema may predispose the client to seizures; therefore stimuli of any kind should be minimized. It is too early to plan for a cesarean birth; other therapies will be tried first. The client will probably be given IV magnesium sulfate to prevent a seizure, not furosemide to promote diuresis. Magnesium sulfate will be used; calcium gluconate is its antidote.

A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply? 1. Trisomy 21 2. Turner syndrome 3. Open neural tube defects 4. Chromosomal aberrations

3. Open neural tube defects An increased level of alpha-fetoprotein (AFP), a fetal serum protein, has been found to reflect open neural tube defects such as spina bifida and anencephaly. Trisomy 21 is revealed by genetic testing of fetal cells. Genetic studies will reveal the presence of just one X chromosome in a female child. Genetic testing, not AFP testing, will reveal chromosomal aberrations.

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? 1. True labor 2. Placenta previa 3. Partial abruptio placentae 4. Abdominal muscular injury

3. Partial abruptio placentae Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.

A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy? 1. Fetal tachycardia 2. Presence of leukorrhea 3. Premature rupture of membranes 4. Imminence of the estimated date of birth

3. Premature rupture of membranes Ruptured membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common because of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. Intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed because of the enlarged abdomen.

What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? 1. "I will take a cool shower before each feeding." 2. "I will drink a couple of quarts of fat-free milk a day." 3. "I will wear a snug-fitting breast binder day and night." 4. "I will apply warm packs and massage my breasts before each feeding."

4. "I will apply warm packs and massage my breasts before each feeding." Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed. 86%of students nationwide answered this question correctly.

A 23-year-old primigravida is at her first prenatal appointment today. Ultrasound indicates that she is at 9 weeks' gestation. She asks when she can first expect to feel her baby move. What is the best response by the nurse? 1. "You should be able to feel the baby move any day now." 2. "You should feel your first light movement of the baby around 24 weeks." 3. "Most women can first detect movement of their babies by 12 to 14 weeks." 4. "Many women are able to first feel light movement between 18 and 20 weeks."

4. "Many women are able to first feel light movement between 18 and 20 weeks." Fetal movement can be felt after 18 weeks and usually by 20 weeks in a primigravida. Fetal movement is normally not felt before 18 weeks' gestation, when the uterus has risen into the abdomen. Fetal movement should continue to be felt at 24 weeks' gestation, but normally is felt 4 to 6 weeks before this time.

What should the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? 1. Bed rest with sedation 2. Trendelenburg position and hydration 3. Preparation for emergency cesarean birth 4. External fetal monitoring and oxygenation

4. External fetal monitoring and oxygenation Fetal monitoring and oxygen administration should be instituted to protect the fetus. Some placental separation has occurred, and it may progress further. Sedation is contraindicated; it may further stress an already compromised fetus. The Trendelenburg position may shift the heavy uterus against the diaphragm and lead to compromised maternal respiratory function, further depriving the fetus of oxygen. Hydration is not a priority at this time. Further assessment of fetal status and progression of abruption placentae is needed before a cesarean birth is considered.

A nurse is teaching breast care to a client who is breastfeeding. Which statement by the client indicates that the teaching has been effective? 1. "I should air-dry my nipples after each feeding." 2. "I should use a mild soap when I wash my breasts." 3. "I'll have to line my breast pads with plastic shields." 4. "I need to take off my bra before I go to bed at night."

1. "I should air-dry my nipples after each feeding." Air-drying nipples after feedings limits irritation and disruption of skin integrity. The application of soap to breast tissue may result in drying and cracking. Plastic liners trap moisture against tissue and may cause skin breakdown. Wearing a brassiere continuously, except while bathing, is recommended for 2 to 3 weeks after delivery to provide support to breast tissue structures.

A registered nurse teaches a nursing student about steps to take to minimize the hazardous effects of maternal drugs on infants during breast-feeding. Which statement of the nursing student indicates the need for additional teaching? 1. "Avoid drugs that have a long half-life in the mother." 2. "Administer sustained-release formulations to the mother." 3. "Use the lowest effective dosage for the shortest possible time." 4. "The mother should be dosed immediately after breast-feeding."

2. "Administer sustained-release formulations to the mother." Sustained-release formulation may have long-term effects on the infant through breast milk. Therefore these drug formulations should be avoided in a mother who is breastfeeding. Drugs that have a long half-life should not be administered to a breast-feeding mother to reduce the toxic effect of the drug on the infant. The lowest effective dosage should be used for the shortest possible time in the mother to reduce the toxic effects to the infant. Drug dosing should be immediately given to the mother after breast-feeding to minimize the drug concentration in the milk at the next feeding.

A new mother who is learning about infant feedings asks the nurse how anyone who is breast-feeding gets anything done with a baby feeding on demand. What is the best response by the nurse? 1. "Most mothers find that feeding whenever the baby cries works out fine." 2. "Perhaps a schedule would be better because the baby is already accustomed to the hospital routine." 3. "Babies on demand feedings eventually set a schedule, so there should be time for you to do other things." 4. "Most breast-feeding mothers find that their babies do better on demand because the amount of milk ingested varies from feeding to feeding."

3. "Babies on demand feedings eventually set a schedule, so there should be time for you to do other things." Most average-sized infants regulate themselves to an approximate 3- to 4-hour schedule, but wide variations do exist. Some episodes of crying do not indicate that the infant is hungry; the mother will learn the difference. It is best to allow the infant to set the schedule. Although it is true that most mothers find that their babies do better with a demand-feeding system, this response does not answer the mother's question about when she will have free time.

A client is admitted with a marginal placenta previa. Which item should the nurse have readily available? 1. One unit of freeze-dried plasma 2. Vitamin K for intramuscular injection 3. Two units of typed and screened blood 4. Heparin sodium for intravenous injection

3. Two units of typed and screened blood A sudden, severe hemorrhage may occur because of the location of the placenta near the cervical os; blood should be ready for administration to prevent shock. Freeze-dried plasma is not used in this situation. Adults manufacture their own vitamin K, and an injection will not help prevent bleeding from the placenta. Heparin sodium is contraindicated in the presence of hemorrhage.

*A 24-year-old client who has performed a positive home pregnancy test has presented at her first prenatal visit. She is 5 feet 6 inches tall (168 cm) and weighs 130 lb (59 kg). What should the nutrition plan regarding her daily caloric intake include? 1. 100 more calories during the first trimester 2. 540 more calories during the third trimester 3. 300 more calories during the three trimesters 4. 340 more calories during the second trimester

4. 340 more calories during the second trimester An extra 340 calories per day during the second trimester is the recommended caloric increase for adult women who are of average weight; this increase will meet the nutritional needs of both fetus and mother during the second trimester. The caloric intake during the first trimester should be about the same as in the nonpregnant state. The increase in caloric intake should be about 460 calories in the third trimester. Caloric needs, as well as caloric intake, vary from trimester to trimester, depending on fetal/maternal energy needs.

*On the third postpartum day a nurse is preparing a breastfeeding mother of twins for discharge. Which statement by the client indicates a potential problem? 1. "I've been urinating large amounts ever since I gave birth." 2. "My flow is bright red with small brown clots the size of my thumb." 3. "My breasts feel full, heavy, and tingly before I breastfeed the babies." 4. "I hope I'll stop being so hungry, because I don't want to gain weight."

2. "My flow is bright red with small brown clots the size of my thumb." Bright-red lochia with thumb-sized brown clots indicates subinvolution and requires further assessment. Urination of large amounts is the expected postpartum diuresis. Breasts that feel full, heavy, and tingly before breastfeeding reflect the influence of the posterior pituitary hormone, oxytocin, that causes the let-down reflex, which is expected before each feeding. An increased appetite is expected with breastfeeding, especially of twins.

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? 1. 8th week of pregnancy 2. 10th week of pregnancy 3. 12th week of pregnancy 4. 18th week of pregnancy

2. 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 client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do. What is the nurse's most appropriate response? 1. "You seem concerned about managing your time. Let's talk about it." 2. "That's up to you; you have to do what works for you." 3. "Holding the baby when feeding is important for development." 4. "It's not safe to prop a bottle. The baby could aspirate the fluid.

1. "You seem concerned about managing your time. Let's talk about it." Asking the client to discuss her concerns about time opens up an area of communication to determine what really is troubling the mother about feeding her baby. The nurse is aware that this is not the best method when using a bottle to feed an infant; the problem of time should be explored with the mother. Holding may be accomplished at times other than feeding periods; telling the client that holding the baby during feedings is important does not explore the client's feelings. Although it is true that it is not safe to prop a baby because of the risk of aspiration, the mother should not be challenged so directly; a gentler explanation should be offered.

During a prenatal examination the nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for what? 1. Acute hemolytic anemia 2. Respiratory distress syndrome 3. Protein Metabolism deficiency 4. Physiological hyperbilirubinemia

1. Acute hemolytic anemia When an Rh-negative woman carries an Rh-positive fetus, there is a risk for the formation of maternal antibodies against Rh-positive blood; antibodies cross the placenta and destroy the fetal red blood cells. Determination of the lecithin/sphingomyelin ratio or the phosphatidylglycerol test, not the Rh factor, may provide information regarding the risk for respiratory distress syndrome (RDS). Testing for the Rh factor will not provide information about protein metabolism deficiency. Physiological bilirubinemia is a common occurrence in newborns; it is not associated with the Rh factor.

After giving birth to a 7-lb 2-oz (3232 g) baby, a client decides that she will breastfeed. What information should the nurse provide to the client regarding breastfeeding? 1. An increase in lochial flow is expected. 2. Weight loss will occur rapidly. 3. Involution of the uterus will be delayed. 4. Application of heat to the breasts is contraindicate

1. An increase in lochial flow is expected. Breastfeeding stimulates oxytocin release and uterine contractions, resulting in increased lochial flow. Weight loss may occur slowly for the breastfeeding mother because of her increased nutritional and caloric needs. The increased levels of oxytocin and subsequent uterine contractions will enhance involution. Heat is not contraindicated, and the client may take warm showers. Warm compresses can be used if the mother experiences problems such as engorgement or sore nipples in order to provide relief.

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? 1. Assess her breastfeeding techniques to identify possible causes. 2. Provide a nipple shield to keep the infant's mouth off the nipples. 3. Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. 4. Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides

1. Assess her breastfeeding techniques to identify possible causes. The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.

A pregnant client arrives on the birthing unit from the emergency department with frank blood running down both legs and a reported low blood pressure. What is the priority nursing intervention? 1. Assessing fetal heart tones 2. Assessing for a prolapsed cord 3. Starting an intravenous (IV) infusion 4. Inserting a uterine pressure catheter

1. Assessing fetal heart tones The priority is determining fetal viability, because it will determine the next intervention. Assessing the client for a prolapsed cord is not the priority. An IV line will be inserted, but it is not the priority. Inserting a pressure catheter might increase the bleeding; it will not yield useful information.

*A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea throughout the day. Which interventions should the nurse recommend? Select all that apply. 1. Focus on and repeat a rhythmic chant. 2. Sit upright for 30 minutes after meals. 3. Take low-sodium antacids after meals. 4. Drink carbonated beverages with meals. 5. Eat small, frequent meals and eat dry crackers in between.

1. Focus on and repeat a rhythmic chant. 5. Eat small, frequent meals and eat dry crackers in between. Focusing helps mitigate odors, tastes, and thoughts that may cause nausea. Avoiding an empty stomach decreases the occurrence of nausea associated with pregnancy. Sitting upright after meals will help ease heartburn, but will have little effect on nausea. Prescribed low-sodium antacids may be taken between meals later in pregnancy to promote relief from heartburn. Carbonated beverages may or may not help; however, women should be advised to consume fluids between, not with, meals.

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. 1. Headache 2. Constipation 3. Abdominal pain 4. Vaginal bleeding 5. Visual disturbances

1. Headache 3. Abdominal pain 5. Visual disturbances Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Visual disturbances in severe preeclampsia are related to retinal edema. Constipation and vaginal bleeding are not related to preeclampsia

At 22 weeks' gestation a client visits the prenatal clinic for the first time. As part of the prenatal workup, the client has blood work performed. The nurse concludes that further assessment is indicated when the laboratory findings show what? 1. Hemoglobin of 10 g/dL (100 mmol/L) 2. Sedimentation rate of 15 mm/hr 3. Blood glucose level of 115 mg/dL (2.98 mmol/L) 4. White blood cell (WBC) count of 9000/mm3

1. Hemoglobin of 10 g/dL (100 mmol/L) A hemoglobin reading below 11 g/dL (110 mmol/L) suggests true anemia rather than physiologic anemia; this occurs because the plasma volume increases more than the red blood cell count during pregnancy, especially during the second trimester. The normal sedimentation rate in women is up to 20 mm/hr; no further assessment is necessary because this is an expected value. The normal blood glucose level ranges from 70 to 105 mg/dL (4.0-6.0 mmol/L); a slightly increased level is common during pregnancy. A WBC count of 5000 to 10,000/mm3 is within expected limits; no further assessment is necessary.

Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. What should the nurse do next? 1. Stop the infusion of magnesium sulfate and notify the primary healthcare provider. 2. Administer calcium gluconate, because it is an antidote to magnesium sulfate. 3. Continue the magnesium sulfate infusion, because the blood pressure is still high. 4. Check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary

1. Stop the infusion of magnesium sulfate and notify the primary healthcare provider. Near-toxic levels of magnesium sulfate are suggested by the disappearance of the knee-jerk reflex and by depressed respirations (fewer than 12 breaths/min). This is a life-threatening situation, and the primary healthcare provider must be notified immediately. Calcium gluconate may be given as an antidote, but the infusion of magnesium sulfate must be stopped first. Magnesium sulfate is not an antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention.

What client behavior indicates to the nurse that a woman needs further teaching regarding breastfeeding her newborn? 1. When she leans forward to place her breast in the infant's mouth 2. If she holds the infant level with her breast while in a side-lying position 3. If she touches her nipple to the infant's cheek at the beginning of the feeding 4. When she puts her finger in the infant's mouth to break the suction after the feeding

1. When she leans forward to place her breast in the infant's mouth When the breast is pushed into the infant's mouth, typically the infant's mouth closes too soon, resulting in inadequate latching on. The infant should be brought to the breast rather than the other way around. Holding the infant level with her breast while in a side-lying position facilitates latching on and maintains the infant's head in correct alignment, which promotes sucking and swallowing. Touching the nipple to the infant's cheek at the beginning of the feeding will stimulate the rooting reflex and promote latching on. Putting her finger in the infant's mouth to break the suction after the feeding prevents trauma to the nipple when the infant is removed from the breast.

A primigravida in her first trimester visits the prenatal clinic for the first time. Which statement illustrates a psychologic reaction to pregnancy that usually occurs in the first trimester? 1. "I know I'm going to be a terrible mother—I'll forget the baby when I go out." 2. "I'm excited about the baby, but I'm not sure that I'm ready to be a mother." 3. "I know I'm going to have a girl. I dreamed that she would be a doctor or a lawyer and be very successful." 4. "I'm so excited about this baby, but I'm so afraid of losing control during labor. I know I'll be a terrible patient."

2. "I'm excited about the baby, but I'm not sure that I'm ready to be a mother." The response "I'm excited about the baby, but I'm not sure that I'm ready to be a mother" reflects the ambivalence about the pregnancy that is typical during the first trimester. The statement "I know I'm going to be a terrible mother—I'll forget the baby when I go out" is a typical response during the third trimester, when the client begins to doubt her ability to be a good parent. Fantasizing about the infant, its sex, and its future is common during the second trimester. Expressing fears about the birthing process and parenting is common during the third trimester.

What should a nurse teach a nonbreastfeeding mother to help relieve the discomfort of engorgement? 1. Empty the breasts manually once a day. 2. Apply cold packs to the breasts frequently. 3. Ask the practitioner to prescribe a medication for pain. 4. Loosen the brassiere until the breast swelling has subsided

2. Apply cold packs to the breasts frequently. Application of cold constricts the vessels and numbs the pain caused by the distention of the vessels with lymph and blood. Emptying the breasts manually once a day is contraindicated because the client is not breastfeeding; this action will stimulate the flow of milk. If the discomfort persists even when the client wears a tight brassiere and applies cold packs, an over-the-counter analgesic should be sufficient for relief. A tight brassiere maintains alignment of blood and lymph vessels and prevents further engorgement.

A client at 24 weeks' gestation is admitted in early labor. What should the nurse take into consideration regarding this client's early gestation? 1. If contractions are regular, labor cannot be stopped effectively. 2. Birth at this gestational age usually results in a severely compromised neonate. 3. Attempts will be made to sustain the pregnancy for 2 or 3 more weeks to ensure neonatal survival. 4. Infants born at 30 to 34 weeks' gestation have a low morbidity rate because of advances in neonatal health care.

2. Birth at this gestational age usually results in a severely compromised neonate. Morbidity and mortality rates among preterm neonates are highest between 24 and 26 weeks' gestation; complications include immature lung tissue, altered cardiac output, patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, and infection. Depending on the status of cervical effacement and dilation the decision may be made to try halting labor with the use of tocolytic medications and limited activity. If possible, the pregnancy should be maintained past 37 weeks' gestation. Neonates born at 34 weeks' gestation are still at high risk.

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? 1. Calling the primary healthcare provider 2. Checking the client's reflexes 3. Determining the client's blood type 4. Administering the prescribed intravenous (IV) normal saline

2. Checking the client's reflexes The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.

While reviewing laboratory results of clients seen at the maternity clinic, the nurse notes that one client's maternal serum alpha-fetoprotein level is lower than expected. What does the nurse recognizes that this may be associated with? 1. Fetal demise 2. Down syndrome 3. Neural tube defects 4. Esophageal obstruction

2. Down syndrome Chromosomal trisomies such as Down syndrome may be marked by a lower-than-typical level of alpha-fetoprotein. Fetal demise, neural tube defects, and esophageal obstruction typically result in increased levels of alpha-fetoprotein.

*A nurse is assessing the effectiveness of a teaching plan regarding self-care and conservative management of gestational hypertension. The nurse confirms that the teaching has been understood when the client notes the importance of what? 1. Eating a low-protein diet 2. Ensuring adequate sodium intake 3. Joining a weight-reduction program 4. Following the prescribed diuretic regimen

2. Ensuring adequate sodium intake Sodium is not restricted, because restriction decreases blood volume, which in turn reduces placental perfusion. Women at risk for preeclampsia are advised to eat a high-protein diet. Losing weight is contraindicated during pregnancy and does not reduce the risk of preeclampsia. Diuretic therapy is contraindicated because it decreases blood volume, which in turn reduces placental perfusion.

Which assessment finding in a pregnant client should prompt the nurse to notify the primary healthcare provider? 1. Slight dependent edema at 38 weeks' gestation 2. Fundal height at the umbilicus at 16 weeks' gestation 3. Fetal heart rate of 150 beats/min at 24 weeks' gestation 4. Maternal heart rate of 92 beats/min at 28 weeks' gestation

2. Fundal height at the umbilicus at 16 weeks' gestation Fundal height should be at the umbilicus at 20 weeks' gestation. This early fundal height increase indicates a hydatidiform mole, a multiple gestation, or a fetal congenital anomaly; at 16 weeks' gestation the fundus is below the umbilicus in a healthy, single pregnancy. Foot and ankle edema is common as pregnancy reaches term; the enlarged uterus presses on the femoral veins, impeding the flow of venous blood from the extremities. A fetal heart rate of 150 beats/min at 24 weeks' gestation and a maternal heart rate of 92 beats/min at 28 weeks' gestation are within the expected ranges during pregnancy

The nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care throughout pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain to the class? Select all that apply. 1. Systemic vasodilation 2. Increased blood volume 3. Increased blood pressure 4. Increased cardiac output 5. Enlargement of the heart 6. Decreased erythrocyte production

2. Increased blood volume 4. Increased cardiac output 5. Enlargement of the heart Blood volume increases to meet the metabolic demands of pregnancy. Increased cardiac output is necessary to accommodate the increased blood volume needed to meet the demands of the growing fetus. Cardiac hypertrophy is a result of the demands made by the increased blood volume and cardiac output. Systemic vasodilation is not expected. There is little variation in blood pressure, but a slight decrease during the second trimester. Erythrocyte production increases; because the plasma volume increases more than the red blood cell count, the hematocrit is lower.

While conducting prenatal teaching, the nurse should explain to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase? 1. Decreased metabolic rate 2. Increased production of estrogen 3. Secretion from the Bartholin glands 4. Supply of sodium chloride to the vaginal cells

2. Increased production of estrogen Increased estrogen production during pregnancy causes hyperplasia of the vaginal mucosa, which leads to increased production of mucus by the endocervical glands. The mucus contains exfoliated epithelial cells. Increased (not decreased) metabolism leads to systemic changes, but does not increase vaginal discharge. The amount of secretion from the Bartholin glands, which lubricates the vagina during intercourse, remains unchanged during pregnancy. There is no additional supply of sodium chloride to the vaginal cells during pregnancy.

*A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter medicine. The nurse explains why she should consult with her primary healthcare provider before taking any oral medications. What physiologic alteration associated with pregnancy may change the client's response to medication? 1. Decreased glomerular filtration rate 2. Longer gastrointestinal emptying time 3. Increased secretion of hydrochloric acid 4. Development of fetal-placental circulation

2. Longer gastrointestinal emptying time Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and the intestines laterally and posteriorly; absorption of some drugs, vitamins, and minerals may be increased because of their slow passage through the gastrointestinal tract. The glomerular filtration rate increases during pregnancy. The amount of gastric secretion is somewhat lower in the first and second trimesters; it increases in the third trimester. The development of fetal-placental circulation is unrelated to the absorption of drugs.

A breastfeeding mother requires treatment for depression. Which drug would be safe to use if the mother wishes to continue breastfeeding the newborn? 1. Fluoxetine 2. Paroxetine 3. Valproic acid 4. Methotrexate

2. Paroxetine Paroxetine can be safely given during breastfeeding. Fluoxetine can easily enter breast milk; therefore this drug would only be used when other selective serotonin reuptake inhibitors are ineffective. Valproic acid is an antiepileptic drug that can be given safely to breastfeeding women. Methotrexate is an anticancer drug that cannot be given during breastfeeding because it enters the breast milk and can cause adverse effects in the baby.

A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She has gained 50 lb (22.7 kg) during the pregnancy, and her face and extremities are edematous. Which complication is this client experiencing? 1. Eclampsia 2. Severe preeclampsia 3. Chronic hypertension 4. Gestational hypertensio

2. Severe preeclampsia With severe preeclampsia, arteriolar spasms result in hypertension and decreased arterial perfusion of the kidneys. This in turn causes an alteration in the glomeruli, resulting in oliguria and proteinuria, retention of sodium and water, and edema. Eclampsia is characterized by seizures; there is no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. Hypertension that is first diagnosed during pregnancy that persists beyond the postpartum period is also considered chronic hypertension. Gestational hypertension is hypertension that first occurs during midpregnancy without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.

A client at 16 weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her that he has genital herpes. What should the nurse include when teaching the client regarding sexual activity? 1. Condoms must be used when the couple is having intercourse. 2. Sexual abstinence should be practiced during the last 6 weeks of pregnancy. 3. It will be necessary to refrain from sexual contact during pregnancy. 4. Meticulous cleaning of the vaginal area after intercourse is essential.

2. Sexual abstinence should be practiced during the last 6 weeks of pregnancy. Abstinence during the 4 to 6 weeks before term is the best way to avoid contracting the virus and having an outbreak before the birth. Because the herpes virus is smaller than the pores of a condom, this type of protection has limited effectiveness. Abstinence is necessary only when disease symptoms are present in the partner and during the last 4 to 6 weeks of pregnancy. Washing is not sufficient to prevent contraction of this virus; contact already has been made.

The nurse assures a breast-feeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? 1. Has several firm stools daily 2. Voids six or more times a day 3. Spits out a pacifier when offered 4. Awakens to feed about every 4 hours

2. Voids six or more times a day The presence of at least six to eight wet diapers each day indicates sufficient breast milk intake. Several firm stools daily may indicate an inadequate amount of fluid ingestion; the stools of breast-feeding neonates should be soft to loose. Spitting out a pacifier is not an indication of adequate milk consumption; some infants need extra sucking stimulation. Awakening to feed every 4 hours is not a reliable indicator of adequate breast milk intake; sleep patterns vary.

Before discharge, a breastfeeding postpartum client and the nurse discuss methods of birth control. The client asks the nurse, "When will I begin to ovulate again?" How should the nurse respond? 1. "You should discuss this at your first clinic visit." 2. "Ovulation will occur after you stop breastfeeding." 3. "Ovulation may occur before you begin to menstruate." 4. "I really can't tell you, because everyone is so different."

3. "Ovulation may occur before you begin to menstruate." If the client is breastfeeding, ovulation and fertility may occur before menstruation resumes. It is the nurse's responsibility to answer the client's questions rather than putting the client off. Ovulation may occur while a woman is breastfeeding because the process of follicular maturation begins when the prolactin level decreases. Declining to answer by claiming that every woman is different evades the question; there are general guidelines that the nurse can share with the client.

A client asks the nurse at the family planning clinic whether contraception is needed while she is breastfeeding. How should the nurse reply? 1. "As long as you aren't having periods, you won't need a contraceptive." 2. "It would be best to delay sexual relations until you have your first period." 3. "You should use contraceptives, because ovulation may occur at any time without a period." 4. "Breastfeeding suppresses ovulation, so you don't need to worry about pregnancy.

3. "You should use contraceptives, because ovulation may occur at any time without a period." Anovulation occurs in nursing mothers for varying periods of time; breastfeeding is not a reliable method of birth control. Periods may not occur for several months; sexual relations need not be delayed until the first period. Ovulation can occur without menstruation. Lactation may delay menses, but does not reliably suppress ovulation.

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do? 1. Use warm, moist towels as compresses. 2. Express milk from each breast manually. 3. Apply cold packs and a snugly fitting bra. 4. Restrict oral fluid intake to less than a quart a day.

3. Apply cold packs and a snugly fitting bra. Application of cold relieves discomfort, and a snug bra provides support and aids in pressure atrophy of acini cells so that milk production is suppressed. Warm, moist compresses are suitable for the breastfeeding mother experiencing discomfort from engorgement because it promotes comfort and stimulates milk production. Expressing milk manually is suitable for the breastfeeding mother who is experiencing engorgement, not one who is formula feeding, because it promotes comfort and stimulates milk production. Restriction of fluids will not prevent engorgement and may cause dehydration.

A client who has been breastfeeding her newborn every 3 hours experiences sore nipples. What should the nurse teach her about easing nipple soreness? 1. Use nipple shields at each feeding. 2. Wash with mild soap when cleansing the nipples. 3. Change the baby's breastfeeding position for each feeding. 4. Allow just the edge of the nipple to be placed in the baby's mouth

3. Change the baby's breastfeeding position for each feeding. If the infant's position is changed for each feeding, the infant will exert pressure on different areas of the nipples while suckling, thereby decreasing the possibility of soreness from constant pressure on one site. Persistent use of nipple shields does not foster effective breastfeeding; the rubber nipple of the shield may cause infant "nipple confusion." The nipples should not be washed with soap, which can cause further irritation. The entire nipple and surrounding areolar tissue should be in the infant's mouth.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? 1. Taking exogenous insulin stimulates fetal growth. 2. Consuming more calories covers the insulin secreted by the fetus. 3. Extra circulating glucose causes the fetus to acquire fatty deposits. 4. Fetal weight gain increases as a result of the common response of maternal overeating.

3. Extra circulating glucose causes the fetus to acquire fatty deposits. It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, where it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases because pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.

A breastfeeding mother asks the nurse how human milk compares with cow's milk. How should the nurse respond? 1. Lactose content is higher in cow's milk than in human milk. 2. Protein content in human milk is higher than in cow's milk. 3. Fat in human milk is easier to digest and absorb than the fat in cow's milk. 4. Immunologic and antiallergenic factors found in human milk are now added to cow's milk

3. Fat in human milk is easier to digest and absorb than the fat in cow's milk. Fat in human milk is easier to digest because of the arrangement of fatty acids on the glycerol molecule. Also, human milk is not heat treated, as is cow's milk when it is pasteurized. The lactose content is higher in human milk. There is less protein in human milk than in cow's milk; however, it is easier for human beings to digest. Human immunologic and antiallergenic factors are found only in human milk, not in cow's milk.

A client making her first visit to the prenatal clinic asks which immunization can be administered safely to a pregnant woman. What should the nurse tell her? 1. Rubella (measles) 2. Rubeola (German measles) 3. Inactive influenza 4. Varicella (chicken pox)

3. Inactive influenza The inactive influenza and diphtheria, tetanus, pertussis (dTAP) immunizations can be safely administered during the first trimester of pregnancy, although dTAP is recommended at 27 to 36 weeks' gestation to provide immunity to the mother and infant. The inactivated influenza vaccine may be given because it is a killed virus vaccine and will not have a teratogenic effect. Rubella (measles) and rubeola (German measles) vaccines are both live viruses that should never be administered during pregnancy because they can have teratogenic effects. Varicella (chicken pox) immunization is not given because it may cause birth defects in the fetus.

A nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation? 1. Inhibin 2. Estrogen 3. Prolactin 4. Progesterone

3. Prolactin Prolactin is the hormone that initiates and produces milk during lactation. Inhibin prevents the secretions of follicle stimulating hormone and gonadotropin releasing hormone. Estrogen and progesterone are the sex hormones produced by the ovaries.

*A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. What should the nurse instruct the client to do? 1. Stop nursing for a few days and allow the nipple to heal. 2. Manually express milk and feed it to the baby in a bottle. 3. Start feedings on the unaffected breast until the affected breast heals. 4. Use a breast shield to keep the baby from making direct contact with the nipple.

3. Start feedings on the unaffected breast until the affected breast heals. The most vigorous suckling occurs during the first few minutes of nursing, as the infant suckles on the unaffected breast; suckling on the affected breast later is less traumatic. Stopping nursing for several days is unnecessary and will interfere with lactation. Manual expression may not completely empty the breast, interfering with lactation. A breast shield confuses an infant because it requires a different suckling pattern to obtain milk.

A client who has been breastfeeding tells the nurse on the third postpartum day that her breasts are painful and that she is afraid that the baby will hurt her while grasping the nipple and suckling. How should the nurse respond at this time? 1. Offering the client an analgesic before breastfeeding 2. Recommending that the client limit fluids for several days 3. Suggesting that the client formula feed the baby for 2 days 4. Helping the client express some milk manually before feeding

4. Helping the client express some milk manually before feeding The pressure and tenderness resulting from accumulated milk can be relieved by manually expressing some of the fluid before feeding. Pain medication may be offered if other measures are unsuccessful; however, medication can be transferred to the infant through breast milk. Also, giving medication is a dependent function of the nurse that requires a prescription. The mother should not limit fluids, especially if she is breastfeeding. Breastfeeding, not formula feeding, should continue as a means of limiting engorgement and aiding milk production.

A client with severe preeclampsia develops eclampsia. After the seizure, the client has a temperature of 102° F (38.9° C). What does the nurse suspect as the cause of the elevated temperature? 1. Excessive muscular activity 2. Development of a systemic infection 3. Dehydration caused by rapid fluid loss 4. Irregularity in the cerebral thermal center

4. Irregularity in the cerebral thermal center Increased electrical charges in the brain during a seizure may disturb the cerebral thermoregulation center in the hypothalamus. Excessive muscular activity usually causes perspiration, leading to a drop in body temperature. One increased reading is not a conclusive sign of infection. Rapid fluid loss does not occur during a seizure; clients with preeclampsia have fluid retention.

The nurse evaluates a new mother who is breastfeeding. The client asks how to care for her nipples. What should the nurse recommend? 1. Putting lanolin cream on the nipples after breastfeeding 2. Applying vitamin E gel to the nipples before breastfeeding 3. Using soap and water to clean the breasts and nipples at least once a day 4. Spreading breast milk on the nipples after the feeding and allowing them to air dry

4. Spreading breast milk on the nipples after the feeding and allowing them to air dry Breast milk is a natural lubricant for the nipples and obviously is not toxic for the infant. Products containing lanolin or vitamin E are not recommended because these may be ingested by the infant. Soap should not be used on the nipples because it has a drying effect, which may precipitate cracking of the nipples.

Before teaching a client about breastfeeding, which information regarding hormonal influences should the nurse fully understand? 1. A high level of progesterone stimulates the secretion of oxytocin. 2. A high level of estrogen stimulates the secretion of lactogenic hormones. 3. Milk secretion is under the control of postpartum hormones starting immediately after birth. 4. Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex

4. Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex Several factors influence the secretion of oxytocin and the let-down reflex; these include suckling; nipple stimulation; sexual activity; and thoughts, sight, and/or odor of the infant. Progesterone does not stimulate the secretion of oxytocin. A high level of estrogen inhibits anterior pituitary gland secretion of lactogenic hormones. Milk secretion is under the control of postpartum hormones, but it starts on the third or fourth day after birth. Colostrum, secreted during the first 2 postpartum days, is under the control of the pregnancy hormones.