Evolve Maternity - At risk
A health care provider determines that a fetus is in a breech presentation. For which complication should the nurse monitor the client?
Nonreassuring fetal signs, indicating prolapse of the cord
The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:
Fetal movement
A nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. For what complication associated with this problem should the nurse monitor this client?
Hypovolemic shock
A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate shows:
Late decelerations
A client with severe preeclampsia in the high-risk unit is receiving an infusion of magnesium sulfate. If eclampsia were to occur, what action would the nurse take first?
Prevent injury
A nurse places a newly admitted client with worsening preeclampsia in a private room. Why is it important for this client to be in a nonstimulating environment?
The probability of tonic-clonic seizures is reduced.
What clinical manifestation requires immediate intervention in a woman with a probable ruptured tubal pregnancy?
Sudden onset of knifelike pain in one of the lower quadrants
A client in preterm labor does not respond to therapy, and birth seems imminent. The client begins to cry and says, "I'm so worried about my baby." What is the nurse's best response?
"All of this must leave you very confused and frightened."
A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How can the nurse evaluate whether the client's bladder is distended?
By palpating the client's suprapubic area gently
A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur?
6th
A client with severe preeclampsia is receiving an IV infusion of magnesium sulfate. The nurse remembers that magnesium sulfate is a:
Central nervous system depressant that blocks neuromuscular transmissions
A client is being prepared for an emergency cesarean birth because of fetal compromise. What is the most important preoperative nursing action?
Confirming the signed consent
A client who has undergone a cesarean birth because of the presence of active genital herpes is transferred to the postpartum unit. What type of isolation precautions does the nurse plan to institute?
Contact
A nurse is assessing a postpartum client for signs of an impending hemorrhage resulting from laceration of the cervix. Besides monitoring the client for a firm uterus, what other assessment is important?
Continuous trickling of blood
What potential complication should the nurse anticipate when a pregnant client has premature rupture of the membranes?
Cord prolapse
What is the best method for the nurse to use when evaluating blood loss in a client with placenta previa?
Count or weigh perineal pads
While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum α-fetoprotein level is lower than is typical. The nurse recognizes that this may be associated with:
Down syndrome
A client who had tocolytic therapy for preterm labor is being discharged. What instructions should the nurse include in the teaching plan?
Limit daily activities.
While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs?
Pulmonary edema has developed.
A nurse is caring for a client with type 1 diabetes on her first postpartum day. When planning care for this client, what changes in the client's insulin requirements does the nurse expect?
Suddenly decrease
A nurse on the postpartum unit is assessing several clients. Which clinical finding requires immediate investigation?
A slow trickle of blood from the vagina
Which client is at risk for a postpartum infection?
A woman who required catheterization after voiding less than 75 mL
Which information is most important for a large-for-gestational-age (LGA) infant of a diabetic mother (IDM)?
Blood glucose level less than 40 mg/dL
What signs and symptoms of withdrawal does the nurse identify in a postpartum client with a history of opioid abuse?
Irritability and muscle tremors
A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response?
"A beta-adrenergic."
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect her diet and insulin needs. How should the nurse respond?
"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."
A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond?
"It must be difficult to lose this baby that was important to you both."
At 12 weeks' gestation a client with a history of frequent spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond?
"It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time."
After an incomplete abortion, a client tells a nurse that although her health care provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse?
"It's when the fetus is expelled but other parts of the pregnancy remain in the uterus."
After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response?
"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."
The family of a pregnant client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the best response by the nurse?
"The progression is slow, so people with myasthenia will spend their younger life with few problems."
During a follow-up appointment, a client at 21 weeks' gestation is found to have hyperemesis gravidarum. The client says, "Why is this happening to me? I don't know whether I can continue like this." What is the best response by the nurse?
"This must be physically and emotionally challenging for you."
Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? (Select all that apply.)
2 Preterm labor 3 Multiple gestation 4 Chromosomal anomalies 5 Bleeding in the first trimester
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 health care provider with the mother. Which signs and symptoms require further evaluation by the health care provider? (Select all that apply.)
1 Decreased urine output 5 Contractions that are regular and 5 minutes apart
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 and she has 2+ protein in her urine and edema of the hands and face. Which signs or symptoms are suggestive that HELLP syndrome is developing? (Select all that apply.)
1 Headache 3 Abdominal pain 5 Flulike symptoms
On her first visit to the prenatal clinic a client with rheumatic heart disease asks the nurse whether she has special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? (Select all that apply.)
1 Iron 3 Folic acid
A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. (Select all that apply.)
1 Oxytocin (Pitocin) 2 Misoprostol (Cytotec) 5 Dinoprostone (Prepidil)
What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? (Select all that apply.)
1 Restricting visitors 4 Maintaining a quiet environment
A pregnant client is concerned that she may have been infected with HIV. What information should a nurse include when counseling this client about HIV testing? (Select all that apply.)
1 The risks of passing the virus to the fetus 2 What positive or negative test results indicate 5 The emotional, legal, and medical implications of test results
A 16-year-old primigravida at 36 weeks' gestation visits the prenatal clinic for a routine examination. Her blood pressure is significantly increased, and there is 1+ proteinuria. The client's blood pressure had been averaging 92/70 mm Hg during her previous prenatal visits. What is the lowest blood pressure that should cause the nurse to become concerned?
122/86 mm Hg -An increase of 30 mm Hg systolic and/or 15 mm Hg diastolic has been removed from the official definition of preeclampsia. The new definition encourages practitioners to consider the total situation in determining a diagnosis of preeclampsia.
A primigravida with type 1 diabetes is having her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur?
24th and 28th weeks of gestation
A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus' lungs are mature enough to sustain extrauterine life?
2:1 -The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4.
A nurse is caring for several pregnant clients in the prenatal clinic. Which client causes the most concern because of her predisposition to placenta previa?
30 years old, gravida 6, para 5
Which pregnant client does the nurse suspect is most likely to have placenta previa?
30 years old, gravida 6, para 5
A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiological response indicates to the nurse that the magnesium sulfate is having a therapeutic effect?
A decrease in frequency and duration of contractions -The purpose of administering magnesium sulfate is to stop preterm labor. It is a tocolytic agent that relaxes uterine smooth muscle. Labor is progressing if dilation of the cervix continues
What should be included in the plan of care for a client with class I cardiac disease during the last weeks of pregnancy?
Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor
When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may :
Allow the clients to express their grief
A pregnant woman at 34 weeks' gestation is being seen at the clinic. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action?
Arranging transportation to the hospital
A nurse withholds methylergonovine maleate (Methergine) from a postpartum client. What clinical finding supports the withholding of the medication?
Blood pressure of 160/90 mm Hg -Methylergonovine maleate can cause hypertension and should not be given to a client with an increased blood pressure.
A nurse who is caring for a client in labor uses nitrazine paper to test the pH of the client's leaking vaginal fluid. What color will the nitrazine paper turn if the leakage is amniotic fluid?
Blue
A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?
Cesarean birth
A client who is in labor is admitted 30 hours after her membranes ruptured. For what condition does the nurse anticipate that the client is most at risk?
Chorioamnionitis -The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection. A prolapsed cord usually occurs shortly after the membranes rupture, not 1½ days later. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Premature separation of the placenta is unrelated to ruptured membranes.
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20 percent effaced and 2 cm dilated, with her membranes intact and contractions 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be?
Contacting the health care provider about the need for a cesarean birth
A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client?
Decreased frequency and duration of contractions -Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions. Although terbutaline may increase blood pressure and pulse, this is a side, not a therapeutic, effect requiring frequent assessments. Terbutaline is not an analgesic. It should stop cervical dilation rather than increase it.
A client is found to have preeclampsia, and bedrest at home is prescribed. It is doubtful that this client will be able to comply because she has two preschool children. What should be included in the plan of care that may help the client follow the prescribed regimen?
Discuss why bedrest is necessary
A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin (Lovenox) for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse who is monitoring the client?
Dyspnea
A client who has missed two menstrual periods arrives at the prenatal clinic with vaginal bleeding and one-sided lower quadrant pain. What condition does the nurse suspect?
Ectopic pregnancy -A tubal ectopic pregnancy causes first-trimester bleeding; unless an embryo and placenta happen to be located in the abdominal cavity, they cannot grow outside the uterus for longer than 10 to 12 weeks without causing the classic signs of pressure and bleeding.
A client who is 21 weeks pregnant loses the baby because of an incompetent cervix. Once the client's physical needs have been assessed and met, what is the best way for the nurse to meet the client's psychological needs?
Encouraging the client to see and hold the baby while still possible
At 30 weeks' gestation a client with class II cardiac disease expresses concern about her labor and asks the nurse what to expect. What does the nurse tell the client to expect if cardiac decompensation occurs?
Epidural anesthesia with a vacuum extraction birth
A nurse is caring for a client with placenta previa who is in labor. What action is most important for the nurse to take?
Evaluating external blood loss by counting pads
A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional observation should be made during every visit?
Evidence of pyelonephritis
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?
Extra circulating glucose causes the fetus to acquire fatty deposits.
A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority evaluation includes fetal status, vital signs, skin color, and urine output. What additional information is essential?
Fundal height
A pregnant client is admitted to the high-risk unit with uterine tenderness and some dark-red vaginal bleeding. Abruptio placentae is diagnosed. What priority evaluation should be included with vital signs, skin color, urine output, and fetal heart rate?
Fundal height
A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?
Gravida I who has had an intrauterine fetal death -Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and high birthweight are not risk factors for DIC.
A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta?
Have the mother breastfeed the newborn
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's first intervention?
Helping the client turn to the side-lying position
A nurse is caring for a client who has had a spontaneous abortion. For what complication should the nurse monitor this client?
Hemorrhage
A health care provider prescribes carboprost (Hemabate) to be administered to a postpartum client with intractable vaginal bleeding. What client factor should alert the nurse to question the prescription?
History of asthma
A nurse is planning for the discharge of a crack-addicted 17-year-old mother and her newborn. What is the most appropriate referral to meet the mother's and infant's needs?
Home health nurse
Which adaptation does the nurse suspect is the result of early decompensation in a pregnant woman with cardiac problems?
Increasing fatigue -Increasing fatigue is one of the early signs of decompensating resulting from an increased cardiac workload. Hemoptysis is a later sign of cardiac decompensation that is associated with pulmonary edema. Tachycardia and generalized edema are later signs of cardiac decompensating and may be accompanied by other signs of heart failure.
The nurse is counseling a pregnant client with type 1 diabetes about medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy?
Insulin
A woman with an active lifestyle is in her 30th week of pregnancy. Which activity will the nurse discourage?
Leg lifts and sit-ups
During the first hour after a cesarean birth, a nurse notes that the client's lochia has saturated one perineal pad. In light of the knowledge of expected lochial flow, what should the nurse conclude that this indicates?
Lochial flow within expected limits
A nurse is teaching a prenatal class about smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching?
Low birth weight
A client at 39 weeks' gestation arrives in the birthing suite reporting that she is having regular contractions. A vaginal examination reveals that the presentation is a double-footling breech. The practitioner decides to proceed to a cesarean birth under regional anesthesia. What is an important intervention to help prevent postoperative maternal complications?
Maintaining adequate hydration
What should the nurse explain to a newly pregnant client with cardiac disease?
Maintenance dosages of cardiac medications will probably be increased.
A breastfeeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. What condition does the nurse suspect?
Mastitis
What is the priority nursing care after an amniocentesis?
Monitoring for signs of uterine contractions -It is possible that stimulation of the uterus resulting from the amniocentesis will cause uterine contractions. Perineal care is not necessary because an amniocentesis is not done by way of the vagina.
A 36-year-old primagravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, what does the nurse identify as the priority of care?
Notifying the primary health care provider about the epigastric pain, headache, and blurred vision
A client at 24 weeks' gestation arrives at the clinic for a routine examination. She tells the nurse, "I feel puffy all over." In light of this statement, what is most important?
Obtaining her blood pressure
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hours ago. Assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?
Obtaining maternal vital signs
A client at 36 weeks' gestation arrives at the prenatal clinic for a routine examination. The nurse determines that the client's blood pressure has increased from 102/60 to 134/88 mm Hg and becomes concerned she may be experiencing mild preeclampsia. What other sign of mild preeclampsia does the nurse anticipate?
Proteinuria of 1+
An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. What is the nurse's most important goal for this client?
Reducing her blood pressure
A nurse is counseling a pregnant woman with type 1 diabetes. What is the most important nursing consideration in the planning of care for this client?
Requirement of intensive prenatal care
A nurse is caring for a client who has severe preeclampsia. For which characteristic of eclampsia should the nurse monitor the client?
Seizures
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 gained 50 lb during the pregnancy, and her face and extremities are edematous. What complication, which occurs in the latter part of pregnancy, does the nurse identify?
Severe preeclampsia
A client at 28 weeks' gestation with previously diagnosed mitral valve stenosis is being evaluated in the clinic. Which sign or symptom indicates that the client is experiencing cardiac difficulties?
Syncope on exertion
After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural childbirth." Which postpartum phase of adjustment does this statement most closely typify?
Taking-in
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?
These accelerations are a sign of fetal well-being.
In what disorder is stimulation of labor contraindicated?
Total placenta previa -A total placenta previa requires a cesarean birth ; early intervention helps ensure a healthy neonate and mother
What is the safest position for a woman in labor when the nurse notes a prolapsed cord?
Trendelenburg -A position in which the mother's head is below the level of the hips helps decrease compression of the cord and therefore maintains the blood supply to the fetus. The prone position is impossible to maintain and will not relieve the pressure of the oncoming head on the cord.A position in which the mother's head is below the level of the hips helps decrease compression of the cord and therefore maintains the blood supply to the fetus. The prone position is impossible to maintain and will not relieve the pressure of the oncoming head on the cord.
A client is admitted with a marginal placenta previa. What should the nurse have available?
Two units of typed and screened blood
Laboratory studies reveal that a pregnant client's blood type is O and she is Rh-positive. Problems related to incompatibility may develop in her infant if the infant is:
Type A or B
A nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. What condition is most frequently associated with late decelerations?
Uteroplacental insufficiency
A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vaginal and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain?
Vaginal hematoma
What is a nurse's most important concern when caring for a client with a ruptured tubal pregnancy?
Diminished cardiac output
At 32 weeks' gestation a client undergoes ultrasound, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term?
Painless vaginal bleeding
A client who is having a difficult labor is found to have cephalopelvic disproportion. Which medical order should the nurse question?
Piggyback another 10-unit bag of oxytocin (Pitocin).
An intravenous infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dosage is twice the usual adult dosage. When a nurse questions the dosage, the health care provider insists that it is the desired dosage and directs the nurse to administer the medication. How should the nurse respond to this directive?
Withhold the dose and notify the nurse manager
A nurse is providing nutritional counseling to a low-income pregnant client who has iron-deficiency anemia. What food should the nurse encourage the client to include in her diet each day to best address this problem?
½ cup of red kidney beans
After a client's membranes rupture spontaneously, the nurse sees the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority.
1 Call for assistance and don sterile gloves 2 Insert two fingers into the vagina and exert upward pressure against the fetal presenting part 3 Put a rolled towel under one hip and place in the modified Sims position 4 Administer oxygen to the mother and monitor fetal heart tones
A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? (Select all that apply.)
1 Heparin (Hep-Lock) 4 Enoxaparin (Lovenox)
A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What side effects indicate that the serum magnesium level may be excessive? (Select all that apply.)
1 Absence of the knee-jerk reflex 5 Respiratory rate of 11 breaths/min
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 3 Abdominal pain 5 Visual disturbances
A client who is at risk for seizures as a result of severe preeclampsia is receiving an IV infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? (Select all that apply.)
3 Respirations of 10/min 4 Loss of patellar reflexes
A client has a diagnosis of an unruptured tubal pregnancy. Which findings correlate with this diagnosis? (Select all that apply.)
3 Unilateral abdominal pain 4 History of a sexually transmitted infection
A practitioner prescribes penicillin G benzathine suspension (Bicillin L-A) 2.45 million units for a client with a sexually transmitted infection (STI). The medication is available in a multidose vial of 10 mL in which 1 mL = 300,000 units. How many milliliters should the nurse administer? Record your answer using one decimal place. ____ mL.
8.2
A client in labor at 39 weeks' gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth?
Active genital herpes
The nurse is caring for a group of postpartum clients. Which one should the nurse monitor most closely?
A grand multipara who just had her sixth child -A grand multipara is a woman who has had at least 6 births . Multiparity contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, leading to postpartum hemorrhage
What should a nurse anticipate about the insulin requirements of a client with diabetes on her first postpartum day?
A sharp, sudden decrease -Insulin requirements may fall suddenly during the first 24 to 48 postpartum hours because the endocrine changes of pregnancy are reversed. Insulin requirements do not suddenly increase, remain unchanged, or decrease slowly and steadily at this time
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing?
Abruptio placentae
A client is found to have gestational hypertension in the 22nd week of gestation. What is a major complication of hypertensive disease associated with pregnancy that the nurse should anticipate?
Abruptio placentae
A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding?
Abruptio placentae -Abruptio placentae is associated with cocaine use; it occurs in the third trimester. Placenta previa is seen in the third trimester but is not associated with cocaine use. A tubal pregnancy is identified in the first trimester. Spontaneous abortion occurs in the first two trimesters.
A client who is pregnant for the first time expels the products of conception at 12 weeks' gestation. The client's blood type is Rh negative. What should the nurse anticipate concerning the administration of Rho(D) immune globulin (RhoGAM)?
Administer RhoGAM within 72 hours of the miscarriage. -Rho(D) immune globulin (RhoGAM) should be given within 72 hours of a miscarriage or birth to have an effect on future pregnancies. RhoGAM is always indicated at the termination of a pregnancy, whether it is at term or before term and whether the fetus is alive or dead. It is not necessary to administer RhoGAM this early.
When entering the room of a client in active labor to answer the call light, the nurse sees that she ashen gray, dyspneic, and clutching her chest. What should the nurse do after pressing the emergency light in the client's room?
Administer oxygen by face mask
A woman in active labor arrives at the birthing unit. She tells the nurse that she was found to have a chlamydial infection the last time she visited the clinic but that she stopped taking the antibiotic after 3 days because she "felt better." What would the nurse anticipate as part of the plan of care, in light of this history?
Administration of antibiotics before delivery
A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to avoid. Which nutrient is included on the list?
Amino acids -PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine, an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people with PKU.
A nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. What prophylactic medication does the nurse anticipate administering during the intrapartum period?
Antibiotic
A client at 9 weeks' gestation asks the nurse in the prenatal clinic whether she may have chorionic villi sampling (CVS) performed during this visit. What should the nurse keep in mind as the optimal time for CVS while formulating a response?
At 10 weeks but no later than 12 weeks
A nurse is caring for a postpartum client who had abruptio placentae. Which finding indicates that disseminated intravascular coagulation (DIC) is occurring?
Bleeding at the venipuncture site
A nurse is caring for a client with preeclampsia who is receiving intravenous magnesium sulfate therapy. What antidote should the nurse have readily available?
Calcium gluconate
A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?
Calcium gluconate
A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider about breech presentations when caring for this client?
Cesarean birth probably will be necessary
A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Folic acid is important for this client because it:
Compensates for a rapid turnover of red blood cells
A client with worsening preeclampsia is admitted to the high-risk unit, and the nurse manager places her in a private room. A nonstimulating environment is important for a client with increased cerebral irritability because it:
Decreases the probability of generalized seizures
A pregnant woman who was admitted to the high-risk maternity unit for severe hyperemesis gravidarum is receiving total parenteral nutrition (TPN). Intralipids are not being administered. For what potential complication should the nurse monitor the client?
Dehydration
A nurse in the clinic, during a routine prenatal visit, notes bruises on the client's upper arms. When questioned, the client responds that her boyfriend was upset and hit her. What is the priority nursing action?
Developing a safety plan with the client
Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identify that indicates the need for further instruction about complications associated with a multiple gestation?
Down syndrome
On reporting to the labor and delivery area a primipara indicates to the nurse that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes, and a cervical assessment reveals that she is in labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques?
During the latent phase of the first stage of labor
A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day?
Encouraging frequent ambulation
A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. What is the most therapeutic nursing intervention for this client at her follow-up appointment?
Encouraging the client to verbalize her feelings about the loss
During a prenatal interview at 20 weeks' gestation, the nurse determines that the client has a history of pica. What is the most appropriate nursing action?
Ensuring that the client's diet is nutritionally adequate
A primigravida is admitted with a ruptured fallopian tube resulting from a tubal pregnancy and surgery is performed to remove the fallopian tube. What should postoperative nursing care include?
Explaining that the client may still be capable of becoming pregnant
A pregnant client with cardiac disease asks a nurse to clarify what she was told about making the birth easier for her. What should the nurse remind her is an option to facilitate birth?
Facilitating the birth with vacuum extraction -Vacuum extraction will decrease the workload of the heart during expulsion and permit a vaginal birth.
During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed?
Family history of genetic abnormalities
A client with type 1 diabetes is scheduled for an amniocentesis at 36 weeks' gestation. She asks the nurse why this is being done so late in her pregnancy. What should the nurse consider before responding?
Fetal lung maturity may be evaluated.
A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates:
Fetal well-being
A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left occiput posterior position. The client's membranes rupture spontaneously. What observation requires the nurse to notify the practitioner?
Greenish amniotic fluid
A nurse is caring for a client who is receiving IV magnesium sulfate for preeclampsia. At 37 weeks' gestation she gives birth to an infant weighing 4 lb. What clinical finding in the newborn may indicate magnesium sulfate toxicity?
Hypotonia
Two days after delivery, a client has a temperature of 101° F (38.3), general malaise, anorexia, and chills. What does the nurse expect to identify on the client's laboratory report?
Increased white blood cell (WBC) count
A client's membranes ruptured 20 hours before admission. The client was in labor for 24 hours before giving birth. For which postpartum complication is she at risk?
Infection
A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse do first?
Insert an intravenous catheter
A client at term is admitted in active labor. She has tested positive for HIV. Which intervention in the standard orders should the nurse question as a risk to the fetus?
Internal fetal scalp electrode
After a deep vein thrombosis developed in a postpartum client, an IV infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do?
Interrupt the infusion and notify the practitioner of the aPTT result -The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds) and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary health care provider should be notified
A client in the 38th week of gestation exhibits a slight increase in blood pressure. The health care provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position?
It increases blood flow to the fetus.
A client is admitted to the high-risk prenatal unit with the diagnosis of placenta previa. What should the nurse instruct the client to do?
Lie on her side to avoid putting pressure on the vena cava -The side-lying position decreases pressure on the vena cava from the gravid uterus, ensuring adequate oxygenation of the fetus. Without proper positioning, breathing techniques will be less effective.
A pregnant client with a history of preterm labor is at home on bedrest. What instructions should a teaching plan for this client include?
Lie on the side with the head raised on a small pillow.
The practitioner diagnoses placenta previa. What does this indicate to the nurse about the condition of the placenta?
Low-lying
What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia?
Maintaining a quiet, darkened environment
At 37 weeks' gestation a client's membranes spontaneously rupture but she does not have contractions. What action is most important in the nursing plan of care for this client?
Monitoring for the presence of fever
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?
Monitoring the client for signs of electrolyte imbalances
A client at 6 weeks' gestation who has type 1 diabetes is attending the prenatal clinic for the first time. The nurse explains that during the first trimester insulin requirements may decrease because:
Morning sickness may lead to decreased food intake.
A nurse who is caring for a postpartum client is concerned because the woman is at risk for hemorrhage. Which factor in the client's history alerted the nurse to this concern?
Multifetal pregnancy
When reviewing the history of a client admitted in preterm labor during her 30th week of gestation, the nurse suspects a risk factor associated with this client's preterm labor. What is this risk factor?
Multiple urinary tract infections
A client in labor is being prepared for a cesarean birth. What is the most important nursing intervention before anesthesia is administered?
Obtaining informed consent
Which client should a nurse suspect is at increased risk for postpartum hemorrhage?
One who gives birth to an infant weighing 9 lb 8 oz -The risk for a postpartum hemorrhage is greater with large infants because the uterine musculature has been stretched excessively, thus impairing uterine contractions after the birth.
A woman in labor arrives at the birthing unit. She tells the nurse, "They told me the last time I was at the clinic that I had chlamydia, but I stopped taking the antibiotic after 3 days because I felt better." What potential neonatal disorder transmitted during birth most concerns the nurse because of the inadequate treatment?
Ophthalmia neonatorum
A sonogram performed on a client in the third trimester demonstrates a low-lying placenta. The nurse should teach the client that she is at risk for:
Painless vaginal bleeding
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?
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.
What should the nurse evaluate before continuing the administration of IV magnesium sulfate therapy to a client with preeclampsia?
Patellar reflexes and urinary output -Adequate urinary output, an indicator of effective renal function, is necessary to prevent toxicity because magnesium sulfate is excreted by the kidneys
A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect?
Placenta previa -A nontender uterus and bright-red bleeding are classic signs of placenta previa ; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed.
The nurse teaches a client who is to undergo amniocentesis that ultrasonography will be performed just before the procedure to determine the:
Position of the fetus and the placenta
A client with heart disease is admitted to the birthing suite. How can the nurse try to prevent the development of cardiac decompensation during her labor?
Positioning her on the side with her shoulders elevated.
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?
Pregnancy will end with the birth of a healthy infant.
A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the priority nursing action is:
Preparing for a cesarean birth
A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client?
Prolapse of the umbilical cord
A client in labor is admitted with a suspected breech presentation. For what occurrence should the nurse be prepared?
Prolapsed cord
Sitz baths are ordered for a client with an episiotomy during the postpartum period. A nurse encourages her to take the sitz baths because they aid the healing process by:
Promoting vasodilation
A client is admitted with a diagnosis of preeclampsia. What significant clinical finding does the nurse expect when reviewing the client's history?
Proteinuria
A client at 36 weeks' gestation is admitted to the high-risk unit because she gained 5 lb 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?
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
A nurse administers the prescribed intravenous dose of magnesium sulfate to a client with severe preeclampsia. What adverse effect should the nurse address when evaluating the client's response to the medication?
Respiratory depression
While a client at 30 weeks' gestation is being examined in the prenatal clinic, the nurse identifies a respiratory rate of 26/min, blood pressure of 100/60, and diaphragmatic tenderness, and the client reports increased urinary output. Which finding indicates that the client may be experiencing a complication?
Respiratory rate
A client being prepared for surgery because of a ruptured tubal pregnancy complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy?
Shock
A client with mild preeclampsia is being treated on an outpatient basis. Three days of bedrest is prescribed. What position should the nurse encourage the client to maintain while in bed?
Side-lying -The side-lying position improves venous return to the heart and increases stroke volume and cardiac output.
A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing:
Sodium
A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. What does the nurse conclude?
The fetus may be compromised in utero.
A nurse is caring for a client at 42 weeks' gestation who is having a contraction stress test (CST). What does a positive result indicate?
The function of the placenta has diminished.
In her 37th week of gestation, a client with type 1 diabetes has amniocentesis to determine fetal lung maturity. The lecithin/sphingomyelin ratio is 2:1, phosphatidylglycerol is present, and creatinine is 2 mg/dL. What conclusion should the nurse draw from this information?
The newborn should be free from respiratory problems. -These test results confirm fetal lung maturity, and the neonate should be free of major respiratory problems. They do not indicate the need for a cesarean birth.
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude?
The nurse should have worn gloves for self-protection.
A client has a blood pressure of 90/50 mm Hg during her first visit to the prenatal clinic. On a subsequent visit, at 34 weeks' gestation, her blood pressure is 120/76 mm Hg. The nurse concludes that could have occurred because of:
The possible development of preeclampsia
A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect?
Threatened abortion
For what complication should the nurse specifically monitor a grand multipara who has just given birth?
Uterine atony
