HESI EAQ - Pregnancy, Labor, Childbirth, Postpartum - At Risk
The nurse in the birthing unit is caring for several postpartum clients. Which factor will increase the risk for hypotonic uterine dystocia? Twin gestation Gestational anemia Hypertonic contractions Gestational hypertension
Twin gestation A multiple gestation thins the uterine wall by overstretching it; therefore the efficiency of contractions is reduced. Gestational anemia is physiologic anemia that is benign; although anemia may cause fatigue during labor, it does not affect uterine contractility. Hypertonic contractions will cause increased discomfort, fatigue, dehydration, and increased emotional distress, not hypotonic uterine dystocia. Therapeutic interventions include rest and sedation. Gestational hypertension may trigger preterm labor; it does not cause hypotonic uterine dysfunction.
A woman with an active lifestyle reaches her thirtieth week of pregnancy. Which activity will the nurse discourage? Yoga Swimming Bicycling Leg lifts and sit-ups
Leg lifts and sit-ups Maintaining the supine position can interrupt blood flow to the fetus and therefore should be avoided after the first trimester. Yoga, swimming, and bicycling are all appropriate activities during pregnancy.
Which assessment finding should the nurse consider to be of concern in a client at 35 weeks' gestation? Frequent painless urination Painful intermittent contractions Increased fetal movement after eating Lower back pain that results in insomnia
Painful intermittent contractions Painful contractions at this time may indicate preterm labor or the presence of preparatory contractions (also known as Braxton Hicks contractions). The client's painful intermittent contractions must be assessed further to distinguish between the two types. Frequent urination is common during the last trimester because of the pressure of the enlarging fetus; painful urination may indicate a urinary tract infection. Fetal movement usually increases after the mother eats. Difficulty sleeping and lower back pain are both common adaptations during the third trimester.
A client at 26 weeks' gestation arrives at the clinic for her scheduled examination. Her blood pressure is 150/86 mm Hg. She tells the nurse that she has gained 5 lb (2.3 kg) in the last 2 weeks. What is the priority nursing action? Testing the client's urine for albumin Taking the client's body temperature Preparing the client for a vaginal examination Scheduling the client for an appointment in a week
Testing the client's urine for albumin Albumin (a protein made by the liver)in the urine is an indication of preeclampsia, as are increased blood pressure and weight gain of more than 2 lb (0.9 kg) per week. Changes in body temperature are not associated with preeclampsia. These signs indicate preeclampsia; treatment does not require a vaginal examination. Scheduling the client for an appointment in a week is premature. More data must be collected and documented first.
On her first visit to the prenatal clinic, a client with rheumatic heart disease asks the nurse whether she has any special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Iron Calcium Folic acid Vitamin C Vitamin B 12
Iron Folic Acid Because pregnant women with heart disease are more likely to have anemia, there may be an additional need for iron and for folic acid. If the pregnant client with heart disease is eating the recommended pregnancy diet and taking prenatal vitamin and mineral supplements, there is no additional need for calcium, vitamin C, or vitamin B 12.
A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows fetal bradycardia, and a change is seen in the contour of the client's abdomen. What is the nurse's priority intervention? Checking the client's vital signs Placing the client on her left side Immediately placing an internal scalp electrode on the fetus Alerting others regarding the need for immediate cesarean delivery
Alerting others regarding the need for immediate cesarean delivery Another nurse should be asked to notify the operating room staff, primary healthcare provider, anesthesiologist, and neonatal team to prepare. The client's nurse should monitor vital signs, watch for signs of hypotension and tachycardia, insert an indwelling catheter, and stay as calm as possible while explaining to the client that the staff are working together to bring about a safe outcome. The client is exhibiting signs of uterine rupture. An emergency cesarean birth is the priority. Vital signs may be checked immediately after another nurse has been asked to bring the team together. Placing an internal fetal monitor is a poor use of valuable time and requires a prescription from the primary healthcare provider. Client history, fetal bradycardia, and change of abdominal contour indicate uterine rupture.
A client with mild preeclampsia is admitted to the high-risk prenatal unit because of a progressive increase in her blood pressure. The nurse reviews the primary healthcare provider's prescriptions. Which prescriptions does the nurse expect to receive for this client? Daily weight Side-lying bed rest 2 g/day sodium diet Deep tendon reflexes Glucose tolerance test
Daily weight Side-lying bed rest Deep tendon reflexes Rapid weight gain is a sign of increasing edema. One liter of fluid is equal to 2.2 lb. Maintaining bed rest promotes fluid shift from the interstitial spaces to the intravascular space, which enhances blood flow to the kidneys and uterus; the side-lying position promotes placental perfusion. A 2 g/day sodium diet will deplete the circulating blood volume, limiting blood flow to the placenta. A moderate sodium intake (6 g or less) is permitted as long as the client is alert and has no nausea or indication of an impending seizure. Deep tendon reflexes should be monitored. Reflexes of +2 are indicative of mild preeclampsia; +4 indicates severe preeclampsia. There are no data indicating that a glucose tolerance test is needed.
A client at 40 weeks' gestation is admitted to the birthing unit in early labor. She tells the nurse that she awakened at 8:00 am and started having regular contractions that were 6 minutes apart. Her last full meal was eaten at about 6:00 pm the preceding day. She did not eat breakfast. Which assessment finding indicates a potential problem? Blood pressure of 120/70 mm Hg Decreased blood glucose level Contractions lasting 35 to 40 seconds Vaginal fluid that tests olive-yellow on a Nitrazine strip
Decreased blood glucose level Labor is hard work and can cause depletion of the pregnant woman's glucose stores, especially if she had not eaten for more than 14 hours. A blood pressure of 120/70 mm Hg is within expected limits and does not indicate a potential problem. Contractions lasting 35 to 40 seconds are typical of early labor. Nitrazine paper that turns a shade of yellow demonstrates that the membranes have not ruptured. This finding does not indicate a potential problem.
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Headache Constipation Abdominal pain Vaginal bleeding Flulike symptoms
Headache Abdominal pain Flulike symptoms Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.
A client with severe preeclampsia develops eclampsia. After the seizure, the client has a temperature of 102° F (38.9° C). What does the nurse suspect as the cause of the elevated temperature? Excessive muscular activity Development of a systemic infection Dehydration caused by rapid fluid loss Irregularity in the cerebral thermal center
Irregularity in the cerebral thermal center Increased electrical charges in the brain during a seizure may disturb the cerebral thermoregulation center in the hypothalamus. Excessive muscular activity usually causes perspiration, leading to a drop in body temperature. One increased reading is not a conclusive sign of infection. Rapid fluid loss does not occur during a seizure; clients with preeclampsia have fluid retention.
The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? Boggy uterus Hypovolemic shock Multiple vaginal clots Bleeding at the venipuncture site
Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.
Which nursing assessment is most important for a large-for-gestational-age (LGA) infant of a diabetic mother (IDM)? Temperature less than 98° F (36.6° C) Heart rate of 110 beats/min Blood glucose level less than 40 mg/dL (2.2 mmol/L) Increasing bilirubin during the first 24 hours
Blood glucose level less than 40 mg/dL (2.2 mmol/L) At birth, circulating maternal glucose is removed; however, the IDM still has a high level of insulin, and rebound hypoglycemia may develop. The temperature-regulating ability of an IDM is similar to that of a healthy neonate, unless the IDM is preterm. A heart rate of 110 beats/min is within the expected range for a newborn. Pathologic jaundice is associated with hemolytic diseases such as Rh and ABO incompatibilities and sepsis, not maternal diabetes.
During a childbirth preparation class, the nurse teacher discusses the importance of the "spurt" of energy that occurs before labor. Why is it important to conserve this energy? Fatigue may increase the progesterone level. Extra energy decreases the intensity of contractions. Extra energy is needed to push during the first stage. Fatigue may influence pain medication requirements.
Fatigue may influence pain medication requirements. Fatigue will interfere with the successful use of other coping strategies such as distraction; this may lead to the client's need for pain medication. Neither fatigue nor energy influences the progesterone level, which is diminished at this stage of the pregnancy. Energy will increase the intensity of contractions. The client does not push during the first stage of labor; pushing is done during the second stage.
A 26-year-old G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb (3.6 kg) since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client? Mild preeclampsia Severe preeclampsia Chronic hypertension Gestational hypertension
Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.
Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion.
Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. In the left-lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase. Maximizing intra-abdominal pressure on the iliac veins will decrease, not increase, blood flow to the pelvic area. Maximizing aortic compression will decrease, not increase, uterine blood flow. Hemoconcentration occurs and uterine perfusion decreases in the standing and sitting positions.
A client with a history of endometriosis gives birth to a healthy infant. She expresses concern that the problems associated with endometriosis will return now that her pregnancy is over. What is the best response by the nurse? "Pregnancy usually cures the problem." "Endometriosis usually causes early menopause." "You may need a hysterectomy if the problems recur." "Breast-feeding will delay the return of the endometriosis."
"Breast-feeding will delay the return of the endometriosis." Lactation delays ovarian function during the postpartum period; therefore lactation will delay the return of endometriosis. Pregnancy temporarily suppresses ovarian function; the aberrant endometrial tissue is still present. Endometriosis may lead to sterility; it does not cause menopause. Conservative medical therapy will be used first; hysterectomy is a last resort.
After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response? "It's premature separation of a normally implanted placenta." "Your placenta isn't implanted securely in place on the uterine wall." "You have premature aging of a placenta that is implanted in your uterine fundus." "The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."
"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening." Implantation of the placenta in the lower uterine segment is the accepted definition of placenta previa. Premature separation of a normally implanted placenta is known as abruptio placentae; it occurs because the placenta is attached insecurely to the uterine wall. Premature aging of a placenta may not lead to placenta previa but will put the fetus in jeopardy.
A client visiting the prenatal clinic for the first time asks the 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? "A sonogram will tell us if there's a twin pregnancy." "There's a 25 percent probability of you having twins." "Your husband's history of being a twin increases your chance of having twins." "There's no greater probability of you having twins than in the general population."
"There's no greater probability of you having twins than in the general population." Fraternal twins may occur as a result of a hereditary trait; however, it is related to the release of two eggs during one ovulation; the fact that the father is a fraternal twin would not influence the female's ovaries to release two eggs during one ovulation. Although it is true that a sonogram will reveal the presence of twins, this response does not answer the client's question. If there is no maternal family history of twin pregnancies, this client's pregnancy with twins would be a chance occurrence equal to the probability found in the general population.
The nurse is caring for a client whose fetus is in a breech presentation. The membranes rupture and meconium appears in the vaginal introitus. What does the nurse recognize this to indicate? A potential for cord prolapse Evidence of fetal heart abnormalities A common occurrence in breech presentations A condition requiring immediate notification of the primary healthcare provider
A common occurrence in breech presentations Sudden rupture of membranes followed by the appearance of meconium occurs in breech presentation when pressure on the fetal abdomen from the contractions forces meconium from the bowel. Cord prolapse is not an absolute; however, it may occur if the presenting part does not fill the pelvic cavity. Fetal heart abnormalities are identified by means of auscultation or continuous electronic fetal monitoring, not by the presence of meconium. Immediate notification of the primary healthcare provider is unnecessary.
A client who is at 26 weeks' gestation tells the nurse at the prenatal clinic that she has pain during urination, back tenderness, and pink-tinged urine. A diagnosis of pyelonephritis is made. What is the most important nursing intervention at this time? Limiting fluid intake Examining the urine for protein Checking for signs of preterm labor Maintaining her on a moderate-sodium diet
Checking for signs of preterm labor Pyelonephritis often causes preterm labor, leading to increased neonatal morbidity and mortality. Fluids should be increased. The inflammatory process may lead to fever, dehydration, and an accumulation of toxins. Proteinuria occurs with preeclampsia; the client's signs and symptoms are indicative of a kidney infection. A moderate-sodium diet is not relevant to the client's problem.
The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? Calling the primary healthcare provider Checking the client's reflexes Determining the client's blood type Administering the prescribed intravenous (IV) normal saline
Checking the client's reflexes The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.
A client with class I heart disease has reached 34 weeks' gestation. Which problem should the nurse anticipate now that the client is in her third trimester? Dyspnea at rest Vasovagal syncope Progressive dependent edema Shortness of breath on exertion
Dyspnea at rest Dyspnea at rest is associated with cardiopulmonary disorders and may be a sign of impending decompensation. Vasovagal syncope is an expected physiologic change. The client with heart disease is more likely to have exertional syncope. Dependent edema commonly occurs in women with uncomplicated pregnancies as they progress toward term. The client with heart disease is more likely to experience generalized edema. In the third trimester, clients with uncomplicated pregnancies complain of shortness of breath on exertion; this is caused by compression of the diaphragm by the enlarging uterus.
A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional assessment should be made during every visit? Signs of hypothyroidism Evidence of urinary tract infection Symptoms of hypoglycemia Presence of hyperemesis gravidarum Evidence of carpal tunnel syndrome
Evidence of urinary tract infection. Presence of hyperemesis gravidarum Pregnant clients with sickle cell anemia are particularly vulnerable to infections, especially of the genitourinary tract; urine specimens should be examined frequently. A client with sickle cell anemia should always be monitored for hydration, so assessment for dehydration from vomiting caused by hyperemesis gravidarum is of high concern. Hypothyroidism affects 1 in 1500 women during pregnancy; women with sickle cell anemia are not at any higher risk for hypothyroidism than the general population. Women with sickle cell anemia are not at an increased risk for carpal tunnel syndrome during pregnancy.
The nurse is counseling a client who is experiencing preterm contractions in the thirty-fifth week of gestation and whose cervix is dilated 2 cm. What should the nurse teach this client regarding sexual intercourse at this time? It should be limited to once a week It is prohibited because it may stimulate labor It should be restricted to the side-lying position It is permitted as long as penile penetration is shallow
It is prohibited because it may stimulate labor Prostaglandins in semen may stimulate labor, and penile contact with the cervix may increase myometrial contractility. Sexual intercourse may cause labor to progress; it is contraindicated for the rest of the pregnancy. The position is irrelevant, because sexual intercourse is contraindicated for the rest of the pregnancy. Regardless of the extent of penile penetration, sexual intercourse may precipitate labor; it is contraindicated for the rest of the pregnancy.
A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. What is the priority medical intervention? Teaching coughing and deep-breathing techniques Sterilizing the surgical site and administering an enema Providing a sterile gown and inserting an indwelling catheter Obtaining informed consent and assessing the client for drug allergies
Obtaining informed consent and assessing the client for drug allergies In an emergency surgical situation when invasive techniques are necessary, it is important to have a signed consent on file as well as a history of the client's known allergies. Teaching coughing and deep-breathing techniques is not a priority in an emergency such as this. In an emergency, sterilization of the surgical site is performed in the operating room; an enema usually is not given before a cesarean, especially to a client who is bleeding, because it may stimulate contractions and worsen the hemorrhage.
A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. What is the nurse's priority intervention? Starting oxygen therapy Administering an opioid Elevating the head of the bed Drawing blood for laboratory tests
Starting oxygen therapy The client is hemorrhaging and has decreased cardiac output. Oxygen is necessary to prevent further maternal and fetal compromise. Administering an opioid will sedate an already compromised fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Although blood should eventually be drawn for laboratory tests, it is not the priority.
A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. What should the nurse's plan of care include? Withholding oral fluid intake Discussing the need for formula feeding Obtaining permission for a paracervical block Applying moist compresses to the perineal area
Withholding oral fluid intake Withholding oral intake of fluids is part of the preparation for a cesarean birth. This client has active herpes, which can be transmitted to the infant during a vaginal birth. A client with herpes may breast-feed. A paracervical block is not used for a planned cesarean birth. Herpes lesions should be kept as dry as possible.
