Chapter 6: Maternal Child
Getting out of bed in a chair Performing light exercise Showering Driving a car Lifting objects of more than 10 pounds
A patient is discharged the same day after ambulatory surgery for a laparoscopic cholescystectomy. The nurse is providing discharge teaching about how many days the patient should wait to engage in certain activities. Place in order the activities from first to last in which the patient may engage.
Lack of the knee-jerk reflex
A patient is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should alert the nurse to intervene?
Threatened
A patient tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her history reveals amenorrhea for the last 2 months and pregnancy confirmation after her first missed period. She is admitted to the high-risk unit because she may be having a spontaneous abortion. What type of abortion is suspected?
"This is when the fetus is expelled but other parts of the pregnancy remains in the uterus."
After an incomplete abortion, a patient tells a nurse that although her health care provider explained what an incomplete abortion was, she did not understand? What is the nurse's best response?
Down syndrome
Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of multiple pregnancy that were explained by the health care provider. Which conditions does the client identify that indicates the need for further instruction about complications associated with a multiple gestation?
Insulin
The nurse is caring for a pregnant woman with type 1 diabetes about medication changes as the pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy?
Fundal height at the umbilicus at 16 weeks' gestation
What assessment finding of a pregnant patient should alert the nurse to notify the health care provider?
Special high-risk care
What does a nurse anticipate will be provided for a newborn of a mother with a history of long standing diabetes?
Encouraging her to continue regularly schedule prenatal care
What is the initial responsibility of a nurse when teaching the pregnant adolescent?
Ausculating the lungs for crackled every 30 minutes
What nursing intervention is specific for patients with cardiac problems who are in active labor?
Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester
Women who become pregnant for the first time at a later reproductive age (35 y/o or older) are at risk for what complications?
Pad the side rails on the bed
A patient with the diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. What precaution should the nurse initiate?
complete abruptio placentae
A patient is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she has severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. What complication does the nurse suspect?
documentation of the amount of bleeding
What nursing intervention should be included when caring for a patient with placenta previa?
uterine atony
A client pregnant with twins is told by a HCP that she is at risk for postpartum hemorrhage. Later, the client asks why. What should the nurse consider is the cause of postpartum hemorrhage before responding in the language the client understands?
"There is no greater probability of having twins than in the general population"
A client visiting the prenatal clinic for the first time asks a nurse about the probability of having twins because her husband is one of a pair of fraternal twins. What is the appropriate response by the nurse?
Check the patient's fundus for firmness
A few hours after being admitted to the hospital with a diagnosis of inevitable abortion, a patient at 16 weeks' gestation begins to experience bearing-down sensations and suddenly expels the products of conception in bed. What should the nurse do first?
Hypoglycemia
A nurse anticipates that newborns of mothers who have diabetes often have tremors, period of apnea, cyanosis, and poor sucking ability. With what complication are these signs associated?
Twin gestation
A nurse in the birthing unit is caring for several clients. Which factor should the nurse anticipate will increase the risk for hypotonic uterine dystocia?
Unusual uterine enlargement
A nurse is assessing a patient with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate?
Hemorrhage
A nurse is caring for a patient who had a spontaneous abortion. For what complication should the nurse assess this patient?
Embryonic defects
A nurse is caring for a patient who had a spontaneous abortion. The patient asks why spontaneous abortions occur. The nurse responds that they are most commonly caused by what?
Rolling of the eyes to one side with a fixed stare
A nurse is monitoring a patient with severe preeclampsia for the onset of eclampsia. What clinical finding indicates an impending seizure?
Blood pressure more than 140 mm
A patient in the prenatal clinic is diagnosed with preeclampsia. What clinical findings support this diagnosis?
Left lateral with head elevated
A patient with class I heart disease is admitted to the birthing suite in active labor. In what position should the nurse place the patient?
Labor may be induced Birth may be vacuum extraction assisted Regional anesthesia may be administered
A pregnant patient with a history of rheumatic heart disease since childhood is concerned about the birth of her baby and asks what to expect. What should a nurse explain about the birth? SELECT ALL THAT APPLY
First 2 days after the birth
A pregnant patient with class II heart disease is concerned that her pregnancy will be an added burden on her already composed heart. A nurse explains that during pregnancy the cardiac system is most compromised during what?
"I was really happy before I got pregnant."
A teenager at 32 weeks' gestation is hospitalized with preeclampsia. She is anorexic and appears depressed. Which comment indicates to the nurse that further exploration of the client's emotional status is indicated?
Test heel blood with a glucose-oxidase strip
How should a nurse screen a newborn of a diabetic mother for hypoglycemia?
A sharp and sudden increase
What should a nurse anticipate about the insulin requirements of a woman with diabetes on her first postpartum day?
48 hours postpartum
When does a nurse caring for a patient with eclampsia determine that the risk for another seizure has subsided?
Bilirubin level
Which clinical indicator should the nurse identify before scheduling a patient for an endoscopic retrograde cholangiopancreatography (ERCP)?
A sharp lower right or left abdominal pain radiating to the shoulder
Which sign or symptom leads a nurse to suspect that a patient has a tubal pregnancy?
Primigravida who is obese
Which woman should the nurse identify is at risk for developing a hypertensive disorder of pregnancy?
Perinatal mortality is two-three times greater in multiple than single births
A nurse counseling a women who was just diagnosed with a multiple gestation. Why does the nurse consider this pregnancy high risk?
"Why did you decide to come to the prenatal clinic?"
A 16 year old adolescent visits the prenatal clinic because she has missed 3 menstrual periods. Before her physical examination she says, "I don't know what the problem is, but I can't be pregnant." What is the nurse most therapeutic response?
Heart rate acceleration in the last half of pregnancy
A nurse in the prenatal clinic is caring for a patient with heart disease who is in the second trimester. What hemodynamic of pregnancy may affect the patient at this time?
Ecchymosis Yellow sclera Pain in RUQ
A nurse is caring for a woman with cholelithiasis and obstructive juandice. When assessing this patient, the nurse should be alert for which common clinical indicators associated with those conditions?
Stop the infusion and start an infusion of dextrose and water
A nurse is monitoring a patient with severe preeclampsia who is receiving an infusion of magnesium sulfate. Assessment reveals a pulse rate of 55/minute, respiration of 12/minute, and a flushed face. What is the next nursing action?
About the 6th week of pregnancy
A nurse is obtaining the health history from a patient with a diagnosis of a ruptured tubal pregnancy. At what point in the pregnancy does the nurse expect the patient to state when the low abdominal and vaginal bleeding started?
Bile flow into the intestine is obstructed
A nurse is preparing a teaching plan for a pregnant patient with a history of cholethiasis. Which info about the ingestion of fatty foods should the nurse include in the teaching plan?
Gestational hypertension
A nurse is reviewing the obstetric history of a patient who had an abruptio placentae. What prenatal condition does the nurse expect the patient to have?
An immediate c-section birth
A nurse notifies the health care provider that a patient has been admitted to the high-risk unit in her 36th week of gestation. She is bleeding, has severe abdominal pain and a rigid fundus, and is demonstrating signs of shock. For what intervention should the nurse prepare?
Deep tendon reflexes of t2
A patient admitted with preeclampsia is receiving magnesium sulfate. Which assessment indicates that a therapeutic level of the medication has been reached?
placenta previa
A patient arrives at the hospital at 38 weeks' gestation with profuse vaginal bleeding. She states that it occurred suddenly with out any contractions. Which condition may the patient be experiencing that requires immediate notification of the health care provider?
Placenta previa
A patient at 28 weeks' gestation has a sonogram. The results reveal a small-for-gestation-age (SGA) fetus and a low-lying placenta. For what complication should the nurse assess this patient during the last trimester of pregnancy?
Concealed hemorrhage
A patient at 37 weeks' gestation arrives at the emergency department stating that she has abdominal pain but no vaginal bleeding. The health care provider diagnosis abruptioplacentae. The patient asks the nurse why it is so painful. What should the consider is the initial cause of the abdominal pain before responding in language the patient will understand?
Apply an electronic fetal monitor
A patient at 37 weeks' gestation is admitted to the birthing unit from the emergency department. She had arrived by ambulance after a motor vehicle accident. Her vital signs are BP: 90/60; P: 108; R:24. She is reporting sharp abdominal pain. What is the priority nursing intervention at this time?
Headache Abdominal pain Visual disturbances
A patient is admitted to the birthing suite with a blood pressure of 150/90 mm HG, 3t proteinura, 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
Hypofibrinogenemia
A patient who had a severe abruptio placentae asks the nurse why there was so much bleeding. What should the nurse consider is the cause of the heavy bleeding before responding in language the patient will understand?
Rebound tenderness
An 18 year old pregnant woman in her first trimester is admitted with an acute onset of RLQ pain at the McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the patient to determine whether the pain is secondary appendicitis?
