ATI Testbank Questions- OB Exam #2 part V

Which measure may prevent mastitis in a breastfeeding client? a. Wearing a tight-fitting bra b. Applying ice packs prior to feeding c. Initiating early and frequent feedings d. Nursing the infant for 5 minutes on each breast

Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the milk. A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.

A pregnant immigrant has an unknown immunization history. When she presents for routine vaccinations, which will the nurse administer? a. Hepatitis B b. Measles c. Rubella d. Varicella

a. Hepatitis B In general, immunizations with live virus vaccines (e.g., measles, mumps, rubella, varicella, smallpox) are contraindicated during pregnancy because they may have teratogenic effects on the fetus. Inactivated vaccines are safe and can be used in women who have a risk of developing diseases such as tetanus, hepatitis B, and influenza.

Which are presumptive signs of pregnancy? (Select all that apply.) a. Quickening b. Amenorrhea c. Ballottement d. Goodells sign e. Chadwicks sign

a. Quickening b. Amenorrhea e. Chadwicks sign

The nurse is planning care for a client in her first trimester of pregnancy who is experiencing nausea and vomiting. Which interventions should the nurse plan to teach this client? (Select all that apply.) a. Suck on hard candy. b. Take prenatal vitamins in the morning. c. Try some herbal tea to relieve the nausea. d. Drink fluids frequently but separate from meals. e. Eat crackers or dry cereal before arising in the morning.

a. Suck on hard candy. d. Drink fluids frequently but separate from meals. e. Eat crackers or dry cereal before arising in the morning. A client experiencing nausea and vomiting should be taught to suck on hard candy, drink fluids frequently but separately from meals, and eat crackers, dry toast, or dry cereal before arising in the morning. Prenatal vitamins should be taken at bedtime because they may increase nausea if taken in the morning. Before taking herbal tea, the client should check with her health care provider.

What data in the clients history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression? a. Teenage depression episode b. Unexpected operative birth c. Ambivalence during the first trimester d. Second pregnancy in a 3-year period

a. Teenage depression episode A personal history of depression is a risk factor for postpartum depression. An operative birth, ambivalence during the first trimester, and two pregnancies in 3 years are not risk factors for postpartum depression.

A pregnant client reports that she works in a long-term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine. As the nurse, you are aware that some immunizations are safe to administer during pregnancy, whereas others are not. Which vaccines could this client receive? (Select all that apply.) a. Tetanus b. Varicella c. Influenza d. Hepatitis A and B e. Measles, mumps, rubella (MMR)

a. Tetanus c. Influenza d. Hepatitis A and B Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe to administer to women who have a risk for contracting or developing the disease. Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus.

A client who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition? a. Congenital anomalies b. Death before or after birth c. Neonatal hypoglycemia d. Neonatal withdrawal syndrome

b. Death before or after birth Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight, abruptio placentae, placenta previa, preterm birth, perinatal mortality, and SIDS. Smoking does not appear to cause congenital anomalies, hypoglycemia, or withdrawal syndrome.

Which of these findings would indicate a potential complication related to renal function during pregnancy? a. Increase in glomerular filtration rate (GFR) b. Increase in serum creatinine level c. Decrease in blood urea nitrogen (BUN) d. Mild proteinuria

b. Increase in serum creatinine level With pregnancy, one would expect the serum creatinine and BUN levels to decrease. An elevation in the serum creatinine level should be investigated. With pregnancy, the GFR increases because of increased renal blood flow and is thus a normal expected finding. A decrease in the blood urea nitrogen level and mild proteinuria are expected findings in pregnancy.

Which is the gravida and para for a client who delivered triplets 2 years ago and is now pregnant again? a. 2, 3 b. 1, 2 c. 2, 1 d. 1, 3

c. 2, 1 She has had two pregnancies (gravida 2); para refers to the outcome of the pregnancy rather than the number of infants from that pregnancy. She is pregnant now, so that would make her a gravida 2. She is para 1 because she had one pregnancy that progressed to the age of viability.

A postpartum client has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen? a. Fresh fruits b. Milk c. Lentils d. Soda

c. Lentils Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.

Which labor and birth information on the client would suggest an increased risk for hemorrhage? a. Precipitous birth after a 12-hour labor b. Cesarean birth of an infant weighing 8 lb, 4 oz c. Vaginal birth of 7-lb infant after a 2-hour labor d. Vaginal birth of 6-lb infant after a 7-hour labor

c. Vaginal birth of 7-lb infant after a 2-hour labor Precipitous labor (<3 hours) is a risk for postpartum hemorrhage; precipitous birth following a normal duration of labor, cesarean birth of an 8-lb, 4-oz infant, and vaginal birth of a 6-lb infant after a 7-hour labor do not increase the risk of postpartum hemorrhage.

Which instruction should be included in the discharge teaching plan to assist the client in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Report any decrease in the amount of brownish red lochia. c. The passage of clots as large as an orange can be expected. d. Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding.

d. Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding. An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. The lochia should decrease in amount. Large clots after discharge are a sign of complications and should be reported.

Which is a positive sign of pregnancy? a. Amenorrhea b. Breast changes c. Fetal movement felt by the woman d. Visualization of fetus by ultrasound

d. Visualization of fetus by ultrasound The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy.

A pregnant woman is the mother of two children. Her first pregnancy ended in a stillbirth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the five-digit system to describe this womans current obstetric history, what should the nurse record? a. 4-1-2-0-2 b. 3-1-2-0-2 c. 4-2-1-0-1 d. 3-1-1-1-3

a. 4-1-2-0-2 Gravida (the first number) is 4 because this woman is now pregnant and was pregnant three times before. Para (the next four numbers) represents the outcomes of the pregnancies and would be described as follows: T: 1 = term birth at 41 weeks of gestation (son) P: 2 = preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter) A: 0 = abortion; none L: 2 = living children, her son and her daughter She is currently pregnant so she is a gravida 4. She had one term infant, two preterm infants, no abortion, and three living children.

Which complaint made by a client at 35 weeks of gestation requires additional assessment? a. Abdominal pain b. Ankle edema in the afternoon c. Backache with prolonged standing d. Shortness of breath when climbing stairs

a. Abdominal pain Abdominal pain may indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae. Ankle edema in the afternoon is a normal finding at this stage of the pregnancy. Backaches while standing is a normal finding in the later stage of pregnancy. Shortness of breath is an expected finding at 35 weeks.

The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include which of the following? (Select all that apply.) a. Anemia b. Dehydration c. Exhaustion d. Postpartum infection e. Failure to attach to her infant

a. Anemia c. Exhaustion d. Postpartum infection e. Failure to attach to her infant Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated. Exhaustion is common after hemorrhage. It may take the new client weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and the attachment processes. The client is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection. The excessive blood loss that this client has experienced is likely to lead to risk for infection rather than dehydration. It is important that all mothers be educated about adequate fluid intake after birth.

The nurse is assessing a patient during a routine prenatal visit. Her pregnancy has been unremarkable, and at her last visit her fundal height measurement was 23 cm. The nurse measures the patients fundal height at 24 cm. What is the next nursing action? a. Ask the patient when she last felt fetal movement. b. Palpate the patients bladder to determine if it is full. c. Review the patients chart for her pattern of weight gain. d. Assess the patients deep tendon reflexes (DTRs) bilaterally at the patella.

a. Ask the patient when she last felt fetal movement. Between 16 and 36 weeks, fundal height measurement corresponds with the weeks of gestation. The patient was last at the clinic at 23 weeks and would be rescheduled to return at 27 week, or in 4 weeks. The fundal height is 3 cm less than it should be, so the nurse is concerned about fetal well-being. Fetal movement is one of the first indicators of fetal well-being. If the patients bladder is full, the fundal height measurement will surpass the expected finding. Weight gain can be an indicator of well-being, nutritional status, and excess fluid volume. It is not as reliable an indicator as fetal movement for well-being. DTRs are assessed routinely to assess for hyperreflexia associated with gestational or pregnancy-induced hypertension.

When a pregnant woman develops ptyalism, what should the nurse advise? a. Chew gum or suck on lozenges between meals. b. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals. c. Take short walks to stimulate circulation in the legs and elevate the legs periodically. d. Use pillows to support the abdomen and back during sleep.

a. Chew gum or suck on lozenges between meals. Some women experience ptyalism, or excessive salivation. The cause of ptyalism may be decreased swallowing associated with nausea or stimulation of the salivary glands by the ingestion of starch. Small frequent meals and use of chewing gum and oral lozenges offer limited relief for some women. All other options include recommendations for pregnant women; however, they do not address ptyalism.

Which factors contribute to the presence of edema in the pregnant client? (Select all that apply.) a. Diet consisting of processed foods b. Hemoconcentration c. Increase in colloid osmotic pressure d. Last trimester of pregnancy e. Decreased venous return

a. Diet consisting of processed foods d. Last trimester of pregnancy e. Decreased venous return Processed foods, which are high in sodium content, can contribute to edema formation. As the pregnancy progresses, because of the weight of the uterus, compression takes place, leading to decreased venous return and an increase in edema formation. A decrease in colloid osmotic pressure would contribute to edema formation and fluid shifting. Hemodilution would also lead to edema formation.

To relieve a leg cramp, what should the client be instructed to perform? a. Dorsiflex the foot. b. Apply a warm pack. c. Stretch and point the toe. d. Massage the affected muscle.

a. Dorsiflex the foot. Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle contraction. Warm packs can be used to relax the muscle, but more immediate relief is necessary, such as dorsiflexion of the foot. Pointing the toes will contract the muscle and not relieve the pain. Because she is prone to blood clots, massaging the affected leg muscle is contraindicated.

Which client data received during report should the nurse recognize as being a postpartum risk factor? a. Gravida 5, para 5 b. Labor duration of 4 hours c. Infant weight greater than 3800 g d. Epidural anesthesia for labor and birth

a. Gravida 5, para 5 Multiparity (five or more deliveries) is a risk factor for postpartum uterine atony and hemorrhage. A labor duration of 4 hours is not a risk factor because it is not a precipitate labor and birth (less than 3 hours), infant weight of 3800 g is not a risk factor because the infant is not macrosomic, and epidural anesthesia is not a risk factor because epidural anesthesia does not affect uterine contractions.

Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.) a. Insufficient emptying b. Feeding every 2 hours c. Supplementing feedings d. Blisters on both nipples e. Alternating breastfeeding positions

a. Insufficient emptying c. Supplementing feedings d. Blisters on both nipples Mastitis may develop because of stasis of milk, inadequate emptying of the breast, skipped feedings, and introduction of bacteria through injured areas of the nipple. Feeding every 2 hours and alternating breastfeeding positions are both interventions that promote emptying of the breasts and support successful breastfeeding.

The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurses priority action? a. Massage the fundus of the uterus. b. Assist the patient out of bed to void. c. Increase the infusion of oxytocin (Pitocin). d. Ask another nurse to bring in a straight catheter tray.

a. Massage the fundus of the uterus. If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment, while the other hand gently but firmly massages the fundus in a circular motion. Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. If the uterus does not remain contracted as a result of uterine massage or if the fundus is displaced, the bladder may be distended. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate or catheterize her to correct uterine atony caused by bladder distention. Note the urine output. When the fundus is boggy, begin uterine massage. Check the womans bladder for distention and have her empty it if necessary. If she is not able to void and the bladder is distended, catheterize the woman. Weigh blood-soaked pads.

The nurse is teaching a pregnant client about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? (Select all that apply.) a. Report watery vaginal discharge. b. Report puffiness of the face or around the eyes. c. Report any bloody show when you go into labor. d. Report visual disturbances, such as spots before the eyes. e. Report any dependent edema that occurs at the end of the day.

a. Report watery vaginal discharge. b. Report puffiness of the face or around the eyes. d. Report visual disturbances, such as spots before the eyes. Watery vaginal discharge could mean that the membranes have ruptured. Puffiness of the face or around the eyes and visual disturbances may indicate preeclampsia or eclampsia. These three signs should be reported. Bloody show as labor starts may mean the mucous plug has been expelled. One of the earliest signs of labor may be bloody show, which consists of the mucous plug and a small amount of blood. This is a normal occurrence. Up to 70% of women have dependent edema during pregnancy. This is not a sign of a pregnancy complication.

Which laboratory result would be a cause for concern if exhibited by a client at her first prenatal visit during the second month of her pregnancy? a. Rubella titer, 1:6 b. Platelets, 300,000/mm3 c. White blood cell count, 6000/mm3 d. Hematocrit 38%, hemoglobin 13 g/dL

a. Rubella titer, 1:6 A rubella titer of less than 1:8 indicates a lack of immunity to rubella, a viral infection that has the potential to cause teratogenic effects on fetal development. Arrangements should be made to administer the rubella vaccine after birth during the postpartum period because administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women receiving the vaccine during the postpartum period should be cautioned to avoid pregnancy for 3 months. The lab values for WBCs, platelets, and hematocrit/hemoglobin are within the expected range for pregnant women.

Nursing measures that help prevent postpartum urinary tract infection include: a. forcing fluids to at least 3000 mL/day. b. promoting bed rest for 12 hours after birth. c. encouraging the intake of orange, grapefruit, or apple juice. d. discouraging voiding until the sensation of a full bladder is present.

a. forcing fluids to at least 3000 mL/day. Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products. The client should be encouraged to ambulate early. Juices such as cranberry juice can discourage bacterial growth. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The client needs to be encouraged to void frequently.

A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates: a. possible infection. b. normal WBC limit. c. serious infection. d. suspicion of a sexually transmitted disease.

a. possible infection. A WBC count in the upper ranges of normal (20,000 to 30,000 cells/mm3) may indicate an infection. An elevated WBC count is anticipated but becomes a concern as it hits the upper range. An elevated WBC count may be an indication of different types of infection.

To evaluate the desired response of methylergonovine (Methergine), the nurse would assess the clients: a. uterine tone. b. pain level. c. blood pressure. d. last voiding.

a. uterine tone. Methylergonovine (Methergine) simulates sustained contraction of the uterus as evidenced by the tone of the uterus. The pain level, blood pressure, and voiding patterns are not related to the effectiveness of the medication.

The nurse is scheduling the next appointment for a healthy primigravida currently at 28 weeks gestation. When will the nurse schedule the next prenatal visit? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks

b. 2 weeks From 29 to 36 weeks, routine prenatal assessment is every 2 weeks. If the pregnancy is high risk, the patient will see the health care provider more frequently.

A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a(n): a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor.

b. 6.5-lb infant after a 2-hour labor. A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction. Delivering a 5-lb, 2-oz infant with outlet forceps would put this client at risk for lacerations because of the forceps. A 7-lb infant after an 8-hour labor is a normal labor progression. Less than 3 hours is rapid and can produce uterine muscle exhaustion. An 8-lb infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid birth and can cause the uterine muscles not to contract.

Early postpartum hemorrhage is defined as a blood loss greater than: a. 500 mL within 24 hours after a vaginal birth. b. 750 mL within 24 hours after a vaginal birth. c. 1000 mL within 48 hours after a cesarean birth. d. 1500 mL within 48 hours after a cesarean birth.

b. 750 mL within 24 hours after a vaginal birth. The average amount of bleeding after a vaginal birth is 500 mL. Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean averages 1000 mL. Late postpartum hemorrhage is 48 hours and later.

Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth? a. Limit the clients oral intake of fluids for the first 24 hours. b. Assist the client in performing leg exercises every 2 hours. c. Ambulate the client as soon as her vital signs are stable. d. Roll a bath blanket and place it firmly behind the clients knees.

b. Assist the client in performing leg exercises every 2 hours. Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bed rest. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The client may not have full return of leg movements, and ambulating is contraindicated. The blanket behind the knees will cause pressure and decrease venous blood flow.

Which physiologic finding is consistent with normal pregnancy? a. Systemic vascular resistance increases as blood pressure decreases. b. Cardiac output increases during pregnancy. c. Blood pressure remains consistent independent of position changes. d. Maternal vasoconstriction occurs in response to increased metabolism.

b. Cardiac output increases during pregnancy. Cardiac output increases during pregnancy as a result of increased stroke volume and heart rate. Systemic vascular resistance decreases while blood pressure remains the same. Maternal blood pressure changes in response to client positioning. In response to increased metabolism, maternal vasodilation is seen during pregnancy.

Following a vaginal birth, a client has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this clinical diagnosis? a. Decrease in blood pressure, with an increase in pulse pressure b. Compensatory response of tachycardia and decreased pulse pressure c. Decrease in heart rate and an increase in respiratory effort d. Flushed skin

b. Compensatory response of tachycardia and decreased pulse pressure Clinical signs consistent with the beginning of hypovolemic shock include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color.

A pregnant client complains that since she has been pregnant, her nose is always stuffed and she feels like she has a cold. Past medical history is negative for respiratory problems such as hay fever, sinusitis, or other allergies. What is the most likely cause for the clients presentation? a. Increased effects of progesterone to maintain the pregnancy b. Effects of estrogen on the respiratory tract c. Development of allergies as a result of pregnancy because of altered immunity d. Increase in fluid consumption during pregnancy leading to overhydration

b. Effects of estrogen on the respiratory tract Increasing estrogen levels during pregnancy can affect the respiratory tract passages, leading to increased vascular responses that manifest as coldlike symptoms. Progesterone, as the hormone of pregnancy, maintains the pregnancy and does not have any direct effects on the maternal respiratory passages. Although it is possible for a client to develop allergies based on exposure to antigen triggers, it is not typically associated with pregnancy states. An increase in fluid may lead to potential edema, but it is not associated with coldlike symptoms.

You are performing assessments for an obstetric client who is 5 months pregnant with her third child. Which finding would cause you to suspect that the client was at risk? a. Client states that she doesnt feel any Braxton Hicks contractions like she had in her prior pregnancies. b. Fundal height is below the umbilicus. c. Cervical changes, such as Goodells sign and Chadwicks sign, are present. d. She has increased vaginal secretions.

b. Fundal height is below the umbilicus. Based on gestational age (20 weeks), the fundal height should be at the umbilicus. This finding is abnormal and warrants further investigation about potential risk. With subsequent pregnancies, multiparas may not perceive Braxton Hicks contractions as being evident compared with their initial pregnancy. Cervical changes such as Goodells and Chadwicks signs should be present and are considered a normal finding. Increased vaginal secretions are normal during pregnancy as a result of increased vascularity.

A patient at 24 week gestation reports to the clinic nurse that she is tired all the time. What is the nurses best response? a. Everyone has chronic anemia at this time in pregnancy. b. Ill make sure your health care provider is informed of your concern. c. Your urine is clean of protein and sugar. You are doing well at this time. d. Make sure you are drinking enough fluid to keep up with the demands of your body.

b. Ill make sure your health care provider is informed of your concern. The patient is experiencing classic signs of physiologic anemia, or an increase in the amount of plasma resulting in a dilution of circulating red blood cells (RBCs). Red blood cell production will continue to increase throughout pregnancy, with a resulting resolution in physiologic anemia. The health care provider will likely order a complete blood count to verify this. The anemia is physiologic and not chronic because there is no decrease in circulating RBCs. The absence of proteinuria and glucosuria is reassuring, but these findings are not correlated with fatigue. Adequate fluid volume intake is essential in pregnancy but is not responsible for the development of physiologic anemia or the corresponding fatigue.

A client in her first trimester complains of nausea and vomiting. She asks, Why does this happen? What is the nurses best response? a. It is due to an increase in gastric motility. b. It may be due to changes in hormones. c. It is related to an increase in glucose levels. d. It is caused by a decrease in gastric secretions.

b. It may be due to changes in hormones. Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause of nausea and vomiting.

Use Ngeles rule to determine the EDD (estimated day of birth) for a client whose last menstrual period started on April 12. a. February 19 b. January 19 c. January 21 d. February 7

b. January 19 Ngeles rule subtracts 3 months from the month of the last menstrual period (month 4 month 3 = January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days = April 19), so the correct answer is January 19.

A clients last menstrual period was June 10. What is her estimated date of birth (EDD)? a. April 7 b. March 17 c. March 27 d. April 17

b. March 17 To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 3 months (March 10), and adds 7 days (March 17). April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of adding 7 days. March is the correct month, but instead of adding 7 days, 17 days were added. April 17 is subtracting 2 months instead of 3.

A client with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? a. Organisms will be inactivated by gastric acid. b. Organisms that cause mastitis are not passed to the milk. c. The infant is not susceptible to the organisms that cause mastitis. d. The infant is protected from infection by immunoglobulins in the breast milk.

b. Organisms that cause mastitis are not passed to the milk. The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infants gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. The client is just producing the immunoglobulin from this infection, so it is not available for the infant.

Which data collected during your assessment may indicate a vaginal wall hematoma? a. Firm uterus at U-1 b. Pulse rate of 110 bpm c. Moderate lochia d. Soreness of perineum

b. Pulse rate of 110 bpm Trauma to the vaginal area from a forceps birth may result in significant blood loss from hematomas or lacerations. Tachycardia is an early sign of compensation for excessive blood loss. If vital signs suggest hemorrhage but excessive bleeding is not obvious, the cause may be concealed bleeding and the formation of a hematoma; a firm fundus, moderate lochia, and soreness of the perineum are normal findings.

Which advice to the client is one of the most effective methods for preventing venous stasis? a. Sit with the legs crossed. b. Rest often with the feet elevated. c. Sleep with the foot of the bed elevated. d. Wear elastic stockings in the afternoon.

b. Rest often with the feet elevated. Elevating the feet and legs improves venous return and prevents venous stasis. Sitting with the legs crossed will decrease circulation in the legs and increase venous stasis. Elevating the legs at night may cause pressure on the diaphragm and increase breathing problems. Elastic stockings should be applied before lowering the legs in the morning.

If the nurse suspects a pulmonary embolism in the client who suddenly complains of chest pain, she or he should immediately: a. assess for abnormal breath sounds. b. apply O2 via tight face mask at 8 to 10 L/min. c. position the client in a supine position with the head of the bed flat. d. monitor pulse oximetry for decreased oxygen saturation.

b. apply O2 via tight face mask at 8 to 10 L/min. Administration of oxygen will increase oxygen saturation and decrease hypoxia; assessing breath sounds and monitoring pulse oximetry provide assessment data but do not correct the problem. A supine position with the head of the bed flat is incorrect because the head of the bed should be elevated to facilitate respiratory function.

If the nurse suspects a complication of a low forceps birth labor, she should immediately: a. administer a strong oral analgesic. b. assess the perineal and vaginal areas. c. assess the position of the uterine fundus. d. review the labor record for duration of second stage.

b. assess the perineal and vaginal areas. A low forceps birth may result in significant vaginal trauma. Assessment will provide information on the extent of trauma of the perineum and vagina. Administering an analgesic may interfere with obtaining an accurate assessment of the problem, assessing the position of the uterine fundus will not provide any information on vaginal or perineal trauma, and reviewing the labor record may support the suspicion that trauma has occurred but will not identify extent of trauma.

30. Before administering methylergonovine (Methergine), the nurse checks the: a. color of the lochia. b. blood pressure. c. location of the fundus. d. last administration of analgesics.

b. blood pressure. Methylergonovine (Methergine) elevates the blood pressure and should not be given to a woman who is hypertensive. The color of the lochia, location of the fundus, and analgesics are not related to the administration of or contraindicated to this medication.

To prevent infection of the reproductive tract, the nurse should instruct the client to: a. change the peripad once per shift. b. cleanse the perineum from front to back. c. perform pericare at least twice during the shift. d. increase fluid intake to 2500 to 3000 mL/day.

b. cleanse the perineum from front to back. Lack of knowledge of hygiene measures increases the risk of postpartum infection. Wiping the perineum from front to back prevents introduction of infection into the reproductive tract from the anal area. Changing the peripad once per shift and performing pericare twice in a shift are incorrect because these interventions should be done at every voiding or bowel elimination, and increasing fluid intake does not prevent infection of the reproductive tract.

The client who is being treated for endometritis is placed in the Fowler position because it: a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.

b. facilitates drainage of lochia. Lochia and infectious material are eliminated by gravity drainage. The Fowler position may not be the position of comfort, but it does allow for drainage. Good hygiene practice aids in preventing the spread of infection to the urinary tract. This position aids in the drainage of lochia and infectious material.

A client has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The client now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to: a. evaluate intake and output of the past 12 hours following birth. b. initiate a rapid response intervention. c. obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs). d. reposition the client and reassess in 15 minutes. Initiate frequent vital sign assessments.

b. initiate a rapid response intervention. Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent client history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the clients complaints of difficulty breathing suggest that the client is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the client can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the client, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.

The nurse knows that late postpartum hemorrhage can be prevented by: a. manually removing the placenta. b. inspecting the placenta after birth. c. administering broad-spectrum antibiotics. d. pulling on the umbilical cord to hasten the birth of the placenta.

b. inspecting the placenta after birth. If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

When the pregnant woman develops changes caused by pregnancy, the nurse recognizes that the darkly pigmented vertical midabdominal line is the: a. epulis. b. linea nigra. c. melasma. d. striae gravidarum.

b. linea nigra. The linea nigra is a dark pigmented line from the fundus to the symphysis pubis. Epulis refers to gingival hypertrophy. Melasma is a different kind of dark pigmentation that occurs on the face. Striae gravidarum (stretch marks) are a different kind of line caused by lineal tears that occur in connective tissue.

The nurse expecting a uterine infection in a postpartum client should assess the: a. episiotomy site. b. odor of the lochia. c. abdomen for distention. d. pulse and blood pressure.

b. odor of the lochia. An abnormal odor of the lochia indicates infection in the uterus. The infection may move to the episiotomy site if proper hygiene is not followed. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and will be more specific.

A client is currently pregnant; she has a 5-year-old son and a 3-year-old daughter. She had one other pregnancy that terminated at 8 weeks. Which are her gravida and para? a. 3, 2 b. 4, 3 c. 4, 2 d. 3, 3

c. 4, 2 She has had four pregnancies, including the current one (gravida 4). She had two pregnancies that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she is classified as a gravida 4. Gravida 4 is correct, but she is para 2; the pregnancy that was terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she would be classified as a gravida 4, not 3.

Following a difficult vaginal birth of a singleton pregnancy, the client starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft and displaced laterally from midline. Vital signs are 99.8 F, pulse 90 beats/min, respirations 20 breaths/min, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated? a. Oxytocin (Pitocin) to be administered in a piggyback solution b. Administration of methylergonovine (Methergine) c. Administration of prostaglandin analogue d. Increase in parenteral fluids

c. Administration of prostaglandin analogue Prostaglandin analogues can be administered intramuscularly to stop uterine bleeding. Although Pitocin may be indicated in an attempt to stop uterine bleeding, it is not administered in a piggyback solution. Methergine is contraindicated in the presence of hypertension. Increasing fluids will not stop uterine bleeding.

For the patient experiencing a postpartum hemorrhage, the health care provider prescribes methylergonovine (Methergine). What assessment must the nurse perform prior to administering this medication? a. Heart rate b. Temperature c. Blood pressure d. Respiratory rate

c. Blood pressure Methylergonovine (Methergine) may be given intramuscularly but it elevates blood pressure and should not be given to a woman who is hypertensive.

As you receive a report, which assessment finding should you recognize as indicative of a vaginal laceration? a. Fundus firm at the umbilicus b. Pulse of 90 bpm, blood pressure of 110/78 mm Hg c. Bright red continuous trickle of blood from vagina d. Client requested pain medication twice during last shift

c. Bright red continuous trickle of blood from vagina Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red color of lochia; a firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being medicated twice in one shift are common findings in the postpartum client.

For the client diagnosed with endometritis, the nurse recognizes that the client should be positioned in the: a. prone position. b. side-lying position. c. Fowler position. d. supine position with the head flat.

c. Fowler position. The Fowler position promotes drainage of lochia from the reproductive tract. The prone position, side-lying position, and supine position do not promote drainage from the reproductive tract.

While the vital signs of a pregnant client in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? a. Have the client stand up and retake her blood pressure. b. Have the client sit down and hold her arm in a dependent position. c. Have the client turn to her left side and recheck her blood pressure in 5 minutes. d. Have the client lie supine for 5 minutes and recheck her blood pressure on both arms.

c. Have the client turn to her left side and recheck her blood pressure in 5 minutes. Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension.

The health care provider reports that the primigravidas fundus can be palpated at the umbilicus. Which priority question will the nurse include in the clients assessment? a. Have you noticed that it is easier for you to breathe now? b. Would you like to hear the babys heartbeat for the first time? c. Have you felt a fluttering sensation in your lower pelvic area yet? d. Have you recently developed any unusual cravings, such as for chalk or dirt?

c. Have you felt a fluttering sensation in your lower pelvic area yet? Quickening is the first maternal sensation of fetal movement and is often described as a fluttering sensation. Quickening is detected at approximately 20 weeks in the primigravida and as early as 16 weeks in the multigravida. The fundus is at the umbilicus at 20 weeks gestation. Lightening is associated with descent of the fetal head into the maternal pelvis and is associated with improved lung expansion. Lightening occurs approximately 2 weeks before birth in the primipara. Fetal heart tones can be detected by Doppler as early as 9 to 12 weeks of gestation. Pica is the craving for non-nutritive substances such as chalk, dirt, clay, or sand. It can develop at any time during pregnancy. It can be associated with malnutrition and the health care provider should monitor the clients hematocrit/hemoglobin, zinc, and iron levels.

What is the best explanation that you can provide to a pregnant client who is concerned that she has pseudoanemia of pregnancy? a. Have her write down her concerns and tell her that you will ask the physician to respond once the lab results have been evaluated. b. Tell her that this is a benign self-limiting condition that can be easily corrected by switching to a high-iron diet. c. Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition. d. Contact the physician and get a prescription for iron pills to correct this condition.

c. Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition. Providing factual information based on physiologic mechanisms is the best option. Although having the client write down her concerns is reasonable, the nurse should not refer this conversation to the physician but rather address the clients specific concerns. Switching to a high-iron diet will not correct this condition. This physiologic pattern occurs during pregnancy as a result of hemodilution from excess blood volume. Iron medication is not indicated for correction of this condition. There is no need to contact the physician for a prescription.

A client notices that the health care provider writes positive Chadwicks sign on her chart. She asks the nurse what this means. Which is the nurses best response? a. It means the cervix is softening. b. That refers to a positive sign of pregnancy. c. It refers to the bluish color of the cervix in pregnancy. d. The doctor was able to flex the uterus against the cervix.

c. It refers to the bluish color of the cervix in pregnancy. Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the cervix, vagina, and labia, called Chadwicks sign. Softening of the cervix is Goodells sign. Chadwicks sign is a probable sign of pregnancy. The softening of the lower segment of the uterus is Hegars sign, which can allow the uterus to be flexed against the cervix.

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the client void and massages her fundus, but the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next? a. Recheck vital signs. b. Insert a Foley catheter. c. Notify the health care provider. d. Continue to massage the fundus.

c. Notify the health care provider. Treatment of excessive bleeding requires the collaboration of the health care provider and the nurses. Do not leave the client alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The client has voided successfully, so a Foley catheter is not needed at this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.

A gravida client at 32 weeks of gestation reports that she has severe lower back pain. What should the nurses assessment include? a. Palpation of the lumbar spine b. Exercise pattern and duration c. Observation of posture and body mechanics d. Ability to sleep for at least 6 hours uninterrupted

c. Observation of posture and body mechanics Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis. Pregnancy should not cause alterations in the spine. Any assessment for malformation should be done early in pregnancy. Certain exercises can help relieve back pain. Rest is important for well-being, but the main concern with back pain is to assess posture and body mechanics.

What is the reason for vascular volume increasing by 40% to 60% during pregnancy? a. Prevents maternal and fetal dehydration b. Eliminates metabolic wastes of the mother c. Provides adequate perfusion of the placenta d. Compensates for decreased renal plasma flow

c. Provides adequate perfusion of the placenta The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy.

Which observation of your client as she ambulates could indicate development of a DVT (deep vein thrombosis)? a. Slow gait b. Shuffling gait c. Stiffness of right leg d. Leans on husband for support

c. Stiffness of right leg Deep vein thrombosis may cause pain on ambulation and stiffness of the affected leg. A slow gait, shuffling gait, and needing ambulatory support are common observations of the postpartum client because of weakness and discomfort of the perineum.

The client with an IUD has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action? a. A therapeutic abortion will need to be scheduled because fetal damage is inevitable. b. Hormonal analyses will be done to determine the underlying cause of the false-positive test result. c. The IUD will need to be removed to avoid complications such as miscarriage or infection. d. The IUD will need to remain in place to avoid injuring the fetus.

c. The IUD will need to be removed to avoid complications such as miscarriage or infection. Pregnancy with an intrauterine device (IUD) in place is unusual but it can occur and cause complications such as spontaneous abortion and infection. A therapeutic abortion is not indicated unless infection occurs.

A pregnant clients mother is worried that her daughter is not big enough at 20 weeks of gestation. The nurse palpates and measures the fundal height at 20 cm, which is even with the womans umbilicus. Which should the nurse report to the client and her mother? a. Youre right. Well inform the practitioner immediately. b. Lightening has occurred, so the fundal height is lower than expected. c. The body of the uterus is at the belly button level, just where it should be at this time. d. When you come for next months appointment, well check you again to make sure that the baby is growing.

c. The body of the uterus is at the belly button level, just where it should be at this time. At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks gestation is located at the level of the umbilicus. Lightening has not yet occurred. At 20 weeks, the uterus should be at the umbilical level. The descent of the fetal head (lightening) occurs in late pregnancy. Waiting until the next appointment avoids the direct question and might increase the anxiety of the mother and grandmother.

Prior to ambulating the client to the bathroom whose admission hemoglobin level was 10.2 g/dL, the nurse should: a. request repeat hemoglobin and hematocrit. b. assess the resting pulse rate. c. dangle her on the side of the bed. d. administer the ordered oral analgesic.

c. dangle her on the side of the bed. Clients with a low hemoglobin level prior to birth will most likely have a drop in the hemoglobin level following birth. A low hemoglobin level will result in dizziness and place the client at risk for fainting when first ambulating. Dangling the client on the side of the bed prior to standing will allow for the blood pressure to stabilize and prevent fainting. Requesting additional labs will delay ambulation at a time when the client needs to empty her bladder, assessing the resting pulse rate will not provide any information about the effect of ambulation on her cardiovascular system, and administering an ordered oral analgesic may contribute to feelings of faintness.

Physiologic anemia often occurs during pregnancy because of: a. inadequate intake of iron. b. the fetus establishing iron stores. c. dilution of hemoglobin concentration. d. decreased production of erythrocytes.

c. dilution of hemoglobin concentration. When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy.

A pregnant client complains of frequent heartburn. The client states that she has never had these symptoms before and wonders why this is occurring now. The best response that the nurse can provide is: a. examine her dietary intake pattern and tell her to avoid certain foods. b. tell her that this is a normal finding during early pregnancy and will resolve as she gets closer to term. c. explain to the client that physiologic changes caused by the pregnancy make her more likely to experience these types of symptoms. d. refer her to her health care provider for additional testing because this is an abnormal finding.

c. explain to the client that physiologic changes caused by the pregnancy make her more likely to experience these types of symptoms. The presentation of heartburn is a normal abnormal finding that can occur in pregnant woman because of relaxation of the lower esophageal sphincter as a result of the physiologic effects of pregnancy. Although foods may contribute to the heartburn, the client is asking why this presentation is occurring, so the nurse should address the cause first. It is independent of gestation. There is no need to refer to the physician at this time because this is a normal abnormal finding. There is no evidence of complications ensuing from this presentation.

A client, gravida 2, para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is palpated 3 cm below the umbilicus. This finding is: a. appropriate for gestational age. b. a sign of impending complications. c. lower than normal for gestational age. d. higher than normal for gestational age.

c. lower than normal for gestational age. By 20 weeks, the fundus should reach the umbilicus. The fundus should be at the umbilicus at 20 weeks, so 3 cm below the umbilicus is an inappropriate height and needs further assessment. This is lower than expected at this date. It may be a complication, but it may also be because of incorrect dating of the pregnancy.

The nurse recognizes that infection may be present in her postpartum client when the client exhibits a temperature of: a. 100.0 F during the first 36 hours postpartum. b. 100.8 F twice in the first 24 hours postpartum. c. 99.6 F on the first postpartum day and 100.4 on the second. d. 100.4 F on the second postpartum day and 100.8 F on the fourth.

d. 100.4 F on the second postpartum day and 100.8 F on the fourth. The definition of puerperal infection is a temperature of 100.4 F or higher after the first 24 hours, occurring on at least two of the first 10 days following childbirth. 100.8 F in the first 24 hours, 100.0 F in the first 36 hours, and 99.6 F on the first day and 100.4 F on the second day do not meet the definition of puerperal infection.

Which temperature indicates the presence of postpartum infection? a. 99.6 F in the first 48 hours b. 100 F for 2 days postpartum c. 100.4 F in the first 24 hours d. 100.8 F on the second and third postpartum days

d. 100.8 F on the second and third postpartum days A temperature elevation to greater than 100.4 F on two postpartum days, not including the first 24 hours, indicates infection. 99.6 F in the first 48 hours is an expected finding because of dehydration. To be classified as an infection, the temperature needs to be greater than 100.4 F. It is anticipated that women have an elevated temperature the first 24 hours.

A nurse is conducting a prenatal history with a patient who is new to the clinic. The woman reports that she had one healthy baby at term, and a miscarriage at 8 weeks. What will the nurse document as the patients GTPAL? a. 21011 b. 20111 c. 30111 d. 31011

d. 31011 Because this is a prenatal history, the client is pregnant. Gravida is the number of times the uterus has been pregnant, which in this case is three. The patient reported one Term birth, no Preterm births, one Abortion or miscarriage, and presumably one Live child.

Which physiologic event may lead to increased constipation during pregnancy? a. Increased emptying time in the intestines b. Abdominal distention and bloating c. Decreased absorption of water d. Decreased motility in the intestines

d. Decreased motility in the intestines Decreased motility in the intestines leading to increased water absorption would cause constipation. Increased emptying time in the intestines leads to increased nutrient absorption. Abdominal distention and bloating are a result of increased emptying time in the intestines. Decreased absorption of water would not cause constipation.

A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all of the time. The patients urine test is positive for hCG. What is the best nursing action related to this information? a. Ask the patient if she has had any nausea or vomiting in the morning. b. Schedule the patient to be seen by a health care provider within the next 4 weeks. c. Send the patient to the maternity screening area of the clinic for a routine ultrasound. d. Determine if there are any factors that might prohibit her from seeking medical care.

d. Determine if there are any factors that might prohibit her from seeking medical care. The patient has presumptive and probable indications of pregnancy. However, she has not sought out health care until late in the first or early in the second trimester. The nurse must assess for barriers to seeking health care, physical or emotional, because regular prenatal care is key to a positive pregnancy outcome. Asking if the patient has nausea or vomiting will only add to the list of presumptive signs of pregnancy, and this information will not add to the assessment data to determine whether the client is pregnant. The patient needs to see a health care provider before the next 4 weeks because she is late in seeking early prenatal care. Ultrasounds must be prescribed by a health care provider and ordering one is not in the nurses scope of practice.

If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. Dilation and curettage (D&C)

d. Dilation and curettage (D&C) D&C allows examination of the uterine contents and removal of any retained placenta or membranes. Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus. Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.

A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider? a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. b. These conditions are abnormal. Refer the client to an ear, nose, and throat specialist. c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.

d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds. As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy. Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone levels increase during pregnancy. The client should be reassured that these symptoms are within normal limits. No referral is needed at this time. Relaxation of the smooth muscles in the respiratory tract is affected by progesterone.

Determine the obstetric history of a client in her fifth pregnancy who had two spontaneous abortions in the first trimester, one infant at 32 weeks gestation, and one infant at 38 weeks gestation. a. G5 T1 P2 A2 L 2 b. G5 T1 P1 A1 L2 c. G5 T0 P2 A2 L2 d. G5 T1 P1 A2 L2

d. G5 T1 P1 A2 L2 This client is in her fifth pregnancy, which is G5, she had one viable term infant (between 38 and 42 weeks gestation), which is T1, she had one viable preterm infant (between 20 and 37 weeks gestation), which is P1, two spontaneous abortions (before 20 weeks gestation), which is A2, and she has two living children, which is L2.

'Which statement by a postpartum client indicates that further teaching is not needed regarding thrombus formation? a. I'll keep my legs elevated with pillows. b. I'll sit in my rocking chair most of the time. c. I'll stay in bed for the first 3 days after my baby is born. d. I'll put my support stockings on every morning before rising.

d. I'll put my support stockings on every morning before rising. Venous congestion begins as soon as the client stands up. The stockings should be applied before she rises from the bed in the morning. The client should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities. As soon as possible, the client should ambulate frequently.

A client in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse give about safe travel during pregnancy? a. Only travel by car during pregnancy. b. Avoid use of the seat belt during the third trimester. c. You can travel by plane until your 38th week of gestation. d. If you are traveling by car stop to walk every 1 to 2 hours.

d. If you are traveling by car stop to walk every 1 to 2 hours. Car travel is safe during normal pregnancies. Suggest that the woman stop to walk every 1 to 2 hours so she can empty her bladder. Walking also helps decrease the risk of thrombosis that is elevated during pregnancy. Seat belts should be worn throughout the pregnancy. Instruct the woman to fasten the seat belt snugly, with the lap belt under her abdomen and across her thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her uterus. Travel by plane is generally safe up to 36 weeks if there are no complications of the pregnancy, so only travelling by car is an inaccurate statement.

A pregnant client notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products as a cleansing solution or makeup. What would the priority nursing intervention be in response to this situation? a. Refer the client to a dermatologist for further examination. b. Ask the client if she has been eating different types of foods. c. Take a culture swab and send to the lab for culture and sensitivity (C&S). d. Let the client know that this is a common finding that occurs during pregnancy.

d. Let the client know that this is a common finding that occurs during pregnancy. This condition is known as chloasma or melasma (mask of pregnancy) and is a result of pigmentation changes relative to hormones. It can be exacerbated by exposure to the sun. There is no need to refer to a dermatologist. Intake of foods is not associated with exacerbation of this process. There is no need for a C&S to be taken. The client should be assured that this is a normal finding of pregnancy.

The clinic nurse confirms that a patient is pregnant. She reports to the nurse that she has regular periods, and the first day of her last period was on January 20. Using Ngeles rule, what due date will the nurse relay to the patient? a. September 23 b. September 27 c. October 23 d. October 27

d. October 27 Ngeles rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and then adding 7 days.

When documenting a client encounter, what term will the nurse use to describe the woman who is in the 28th week of her first pregnancy? a. Multigravida b. Multipara c. Nullipara d. Primigravida

d. Primigravida A primigravida is a woman pregnant for the first time. A multigravida has been pregnant more than once. A nullipara is a woman who has never been pregnant or has not completed a pregnancy of 20 weeks or more. A primipara has delivered one pregnancy of at least 20 weeks. A multipara has delivered two or more pregnancies of at least 20 weeks.

Which physiologic findings are seen with respect to gallbladder function that might lead to the development of gallstones during pregnancy? a. Decrease in alkaline phosphatase levels compared with nonpregnant women b. Increase in albumin and total protein as a result of hemodilution c. Hypertonicity of gallbladder tissue d. Prolonged emptying time

d. Prolonged emptying time Prolonged emptying time is seen during pregnancy and may lead to the development of gallstones. In pregnancy, there is a twofold to fourfold time increase in alkaline phosphatase levels as compared with those in nonpregnant woman. During pregnancy, a decrease in albumin level and total protein are seen as a result of hemodilution. Gallbladder tissue becomes hypotonic during pregnancy.

Which of the client health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy? a. Sexual intercourse two or three times weekly b. Moderate exercise for 30 minutes daily c. Working 40 hours a week as a secretary in a travel agency d. Relaxing in a hot tub for 30 minutes a day, several days a week

d. Relaxing in a hot tub for 30 minutes a day, several days a week Pregnant women should avoid activities that might cause hyperthermia. Maternal hyperthermia, particularly during the first trimester, may be associated with fetal anomalies. She should not be in a hot tub for more than 10 minutes at less than 100 F. Sexual intercourse is generally safe for the healthy pregnant woman; moderate exercise during pregnancy can strengthen muscles, reduce backache and stress, and provide a feeling of well-being; working during pregnancy is acceptable as long as the woman is not continually on her feet or exposed to environmental toxins and industrial hazards.

The patient reports that the first day of her last normal menstrual period was December 8. Using Ngeles rule, what date will the nurse identify as the estimated date of birth? a. March 1 b. March 15 c. September 1 d. September 15

d. September 15 Ngeles rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and adding 7 days. The incorrect responses add months instead of subtracting months and subtract days instead of adding days.

Why should a woman in her first trimester of pregnancy expect to visit her health care provider every 4 weeks? a. Problems can be eliminated. b. She develops trust in the health care team. c. Her questions about labor can be answered. d. The conditions of the expectant mother and fetus can be monitored.

d. The conditions of the expectant mother and fetus can be monitored. This routine allows for monitoring maternal health and fetal growth and ensures that problems will be identified early. All problems cannot be eliminated because of prenatal visits, but they can be identified. Developing a trusting relationship should be established during these visits, but that is not the primary reason. Most women do not have questions concerning labor until the last trimester of the pregnancy.

While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions? a. These contractions may indicate preterm labor. b. These are contractions that never cause any discomfort. c. Braxton Hicks contractions only start during the third trimester. d. These occur throughout pregnancy, but you may not feel them until the third trimester.

d. These occur throughout pregnancy, but you may not feel them until the third trimester. Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy.

The client has just learned she is pregnant and overhears the gynecologist saying that she has a positive Chadwicks sign. When the client asks the nurse what this means, how should the nurse respond? a. Chadwicks sign signifies an increased risk of blood clots in pregnant women because of a congestion of blood. b. That sign means the cervix has softened as the result of tissue changes that naturally occur with pregnancy. c. This means that a mucous plug has formed in the cervical canal to help protect you from uterine infection. d. This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix.

d. This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix. Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and labia. This discoloration, referred to as Chadwicks sign, is one of the earliest signs of pregnancy. Although Chadwicks sign occurs with hyperemia (congestion with blood), the sign does not signify an increased risk of blood clots. The softening of the cervix is called Goodells sign, not Chadwicks sign. Although the formation of a mucous plug protects from infection, it is not called Chadwicks sign.

Which suggestion is appropriate for the pregnant client who is experiencing heartburn? a. Drink plenty of fluids at bedtime. b. Eat only three meals a day so the stomach is empty between meals. c. Drink coffee or orange juice immediately on arising in the morning. d. Use Tums or Alkamints to obtain relief, as directed by the health care provider.

d. Use Tums or Alkamints to obtain relief, as directed by the health care provider. Antacids high in calcium (e.g., Tums, Alkamints) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the woman to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach.

To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should frequently assess: a. temperature. b. lochial flow. c. fundal height. d. breath sounds.

d. breath sounds. Pulmonary edema is a potential adverse effect of carboprost tromethamine (Hemabate). Auscultation of breath sounds will identify pulmonary edema; temperature, lochial flow and fundal height are not affected by this medication.

To prevent infection of the urinary tract, the nurse should instruct the client to: a. include soft drinks in the total fluid intake. b. drink grapefruit juice several times a day. c. perform pericare at least twice during a shift. d. increase fluid intake to 2500 to 3000 mL/day.

d. increase fluid intake to 2500 to 3000 mL/day. Drinking 2500 to 3000 mL of fluid each day will dilute the bacterial count and flush the infection from the bladder. Ingesting soft drinks and grapefruit juice increase urine alkalinity, which provides a medium for bacterial growth; pericare performed twice during a shift is not frequent enough to remove bacteria, and pericare should be done at each voiding or bowel movement.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests: a. uterine atony. b. perineal hematoma. c. infection of the uterus. d. lacerations of the genital tract.

d. lacerations of the genital tract. Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus would not be firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus, there would be an odor to the lochia and systemic symptoms such as fever and malaise.

A sign of thrombophlebitis is: a. visible varicose veins. b. positive Homans sign. c. pedal edema in the affected leg. d. local tenderness, heat, and swelling.

d. local tenderness, heat, and swelling. Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the client to thrombophlebitis, but are not a sign. A positive Homans sign is indicative of deep vein thrombosis (DVT).

If a late postpartum hemorrhage is documented on a client who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred: a. on the first postpartum day. b. during recovery phase of labor. c. during the third stage of labor. d. on the second postpartum day.

d. on the second postpartum day. A late postpartum hemorrhage occurs after the first 24 hours and up to 12 weeks after birth. The first postpartum day, during the recovery phase, and during the third stage are all within the first 24 hours after birth and would be classified as early postpartum hemorrhage.

The nurse should expect medical intervention for subinvolution to include: a. oral fluids to 3000 mL/day. b. intravenous fluid and blood replacement. c. oxytocin intravenous infusion for 8 hours. d. oral methylergonovine maleate (Methergine) for 48 hours.

d. oral methylergonovine maleate (Methergine) for 48 hours. Methergine provides long-sustained contraction of the uterus. There is no correlation between dehydration and subinvolution. There is no indication that excessive blood loss has occurred. Oxytocin provides intermittent contractions.

If a DVT (deep vein thrombosis) is suspected, the nurse should: a. perform a Homans sign on the affected leg. b. dorsiflex the foot of the affected leg. c. palpate the affected leg for edema and pain. d. place the client on bed rest, with the affected leg elevated.

d. place the client on bed rest, with the affected leg elevated. Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.