Maternity - Antepartum
The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement? 1. "An increase in pulse rate occurs." 2."A decrease in blood volume occurs." 3."A decrease in cardiac output occurs." 4."The blood pressure increases by 20 mm Hg."
Answer: 1 Between 14 and 20 weeks' gestation, the maternal pulse rate increases slowly by 10 to 15 beats/minute, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy.
The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2."My insulin dose will likely need to be increased during the second and third trimesters." 3."Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4."My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."
Answer: 1 Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? 1. The client's last baby weighed 10 pounds at birth. 2. The client's previous deliveries were by cesarean section. 3. The client has a family history of cardiovascular disease. 4.The client is 5 feet, 3 inches tall and weighs 165 pounds.
Answer: 1 Known risk factors that increase the risk of developing gestational diabetes include obesity (more than approximately 198 pounds, depending on height), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (greater than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes.
During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? 1. "Diet and insulin needs change during pregnancy." 2."I will plan my diet based on the results of urine glucose testing." 3."I will need to eat 600 more calories every day because I am pregnant." 4."I can continue with the same diet as before pregnancy, as long as it is well balanced."
Answer: 1 The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. An increase of 600 calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the second and third trimesters, insulin needs increase.
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1. The client has a history of intravenous drug use. 2.The client has a significant other who is heterosexual. 3.The client has a history of sexually transmitted infections. 4.The client has had one sexual partner for the past 10 years. 5.The client has a previous history of gestational diabetes mellitus.
Answer: 1, 3 HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1. Proteinuria 2.Hypertension 3.Low-grade fever 4.Generalized edema 5.Increased pulse rate 6.Increased respiratory rate
Answer: 1,2 The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function 5.Prevents large particles such as bacteria from passing to the fetus 6.Provides an exchange of nutrients and waste products between the mother and the fetus
Answer: 1,2,3,4 The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.
The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1. Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Positive pregnancy test 5.Fetal heart rate detected by a nonelectronic device 6.Outline of fetus via radiography or ultrasonography
Answer: 1,2,3,4 The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.
The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply 1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2."One vein carries oxygenated blood from the placenta to the fetus." 3."The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." 4."Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5."Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."
Answer: 1,2,4 he ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart tone range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.
The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply. 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 2."Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." 3."The low levels of estrogen and progesterone increase the release of the follicle-stimulating hormone and luteinizing hormone." 4."The high levels of estrogen and progesterone promote the release of the follicle-stimulating hormone and luteinizing hormone." 5."The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy."
Answer: 1,5 Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation. All other options are incorrect.
The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? "Your type of pelvis has a narrow pubic arch." 2."Your type of pelvis is the most favorable for labor and birth." 3."Your type of pelvis is a wide pelvis, but it has a short diameter." 4."You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."
Answer: 2 A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2."The vaginal discharge may be bothersome but is a normal occurrence." 3."Report to the emergency department at the maternity center immediately." 4."Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."
Answer: 2 Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? 1. Age 35 years 2.History of syphilis 3.History of genital herpes 4.History of diabetes mellitus
Answer: 2 Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion, although the presence of active lesions at the time of birth presents concerns. Maternal age greater than 40 years and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations, not abortions.
The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? 1. Soft cheese 2. Dried fruits 3. Creamed spinach 4. Fresh-squeezed orange juice
Answer: 2 The best source of calcium is dairy products. Women with lactose intolerance need other sources of calcium. Calcium is present in dark green leafy vegetables, broccoli, legumes, nuts, and dried fruits. Soft cheese is a dairy product and is not tolerated well by the client with lactose intolerance. Some hard cheeses are well aged and may be permissible on a lactose-free diet. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. In addition, creamed spinach may not be tolerated by a client with lactose intolerance. Orange juice does not contain significant amounts of calcium unless fortified with calcium.
The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1. "I will record the number of movements or kicks." 2."I need to lie flat on my back to perform the procedure." 3."If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." 4."I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."
Answer: 2 The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the primary health care provider PHCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the PHCP.
A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response? 1. "This test measures your ability to tolerate the pregnancy." 2. "This test measures amniotic fluid volume and fetal activity." 3. "This test measures your cardiac status and ability to tolerate labor." 4. "This test measures only the amount of amniotic fluid present in the uterus."
Answer: 2 he BPP assesses 5 parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a BPP, each of the 5 parameters contributes 0 to 2 points, with a score of 8 considered normal and a score of 10 perfect. Results are available immediately. A BPP test deals with fetal, not maternal, well-being. Options 1 and 3 relate to maternal well-being. Amniotic fluid measurement is only 1 component of the BPP test.
The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. 1. Use of diaphragm 2.Use of fertility medications 3.History of Chlamydia 4.Use of an intrauterine device 5.History of pelvic inflammatory disease (PID)
Answer: 2,3,4,5 An ectopic pregnancy is one that establishes itself somewhere other than inside the uterus. Multiple factors may predispose a woman to an ectopic pregnancy. Fertility medications, history of sexually transmitted infections, intrauterine devices, and PID have all been associated with ectopic pregnancy. There are no data to support any additional risk for ectopic pregnancy with the use of the diaphragm.
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventive measure may be prescribed. 2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.
Answer: 2,3,5 The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, will likely be prescribed due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.
The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? 1. The client is 28 years of age. 2.This is the second pregnancy. 3.The client has a history of hypertension. 4.The client performs moderate exercise on a regular daily schedule.
Answer: 3 Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure. 2.Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.
Answer: 3 Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the primary health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1. The client is measuring large for gestational age. 2.The client is measuring small for gestational age. 3.The client is measuring normal for gestational age. 4.More evidence is needed to determine size for gestational age.
Answer: 3 During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2."Meat does not provide iron and should be avoided." 3."The iron is best absorbed if taken on an empty stomach." 4."On the days that I eat green leafy vegetables or calf liver, I can omit taking the iron supplement."
Answer: 3 Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach such as between meals, but many women find the side effects worse when iron is taken without food. Taking iron at bedtime may make it easier to tolerate. Taking it with a fluid high in ascorbic acid such as tomato juice also enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.
The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? 1. Checking for edema 2.Monitoring daily weight 3.Monitoring the apical pulse 4.Monitoring the temperature
Answer: 3 Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Edema and weight gain are more of a concern for the client with preeclampsia or gestational hypertension, and an elevated temperature is an indicator of infection.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. "It connects the pulmonary artery to the aorta." 2."It is an opening between the right and left atria." 3."It connects the umbilical vein to the inferior vena cava." 4."It connects the umbilical artery to the inferior vena cava."
Answer: 3 The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's bestresponse? 1. "It promotes the fertilized ovum's chances of survival." 2."It promotes the fertilized ovum's exposure to estrogen and progesterone." 3."It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4."It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."
Answer: 3 The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.
Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1. It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.
Answer: 3,5 The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.
The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? 1.Milk 2.Potatoes 3.Cantaloupe 4.Whole-grain cereal
Answer: 4 Dietary sources of iron include lean meats; liver; shellfish; dark green, leafy vegetables; legumes; whole grains and enriched grains; cereals; and molasses. Milk is high in calcium and also contains phosphorus. Potatoes and cantaloupe are high in vitamin C.
The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item? 1. Tea 2.Milk 3.Coffee 4.Orange juice
Answer: 4 Foods containing ascorbic acid will increase the absorption of iron. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements. Tannin and caffeine in tea decrease iron absorption. Calcium and phosphorus in milk also decrease iron absorption. Coffee binds iron, prevents it from being fully absorbed, and contains caffeine.
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? 1. "I will drink 8 oz of water with each meal." 2."I will eat 3 servings of cracked wheat bread each day." 3."I will eat 2 saltine crackers before I get up each morning." 4."I will eat fresh fruits and vegetables for snacks and for dessert each day."
Answer: 4 Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums
The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? 1. Milk 2.Yogurt 3.Bananas 4.Leafy green vegetables
Answer: 4 Leafy green vegetables are rich in folate (folic acid). Milk and yogurt supply calcium; bananas provide potassium.
The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid? 1. Pork 2.Cheese 3.Chicken 4.Dried peas
Answer: 4 Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Pork, cheese, and chicken are not high in folic acid. Pork is a good source of thiamine. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Tell the client that the fetal heart rate is normal. 4. Notify the primary health care provider (PHCP).
Answer: 4 The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the PHCP. Options 2 and 3 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the PHCP needs to be notified.
The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the primary health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? 1. "This is necessary to relieve your anxiety." 2."This is necessary to eliminate the need for further uncomfortable screenings." 3."This is necessary to minimize the financial cost of caring for an HIV-positive client." 4."This is necessary to assist in identifying potential infections that may need to be treated."
Answer: 4 The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include, for example, Candida infections, genital herpes, and anogenital condyloma. Early reporting of signs and symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being.
A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? 1."I will need to remain on bed rest for 2 weeks." 2."I will need to take a full course of antibiotic treatment." 3."I will need to take tocolytic medication to halt the labor process." 4."I will need to prepare myself and my family for the loss of this pregnancy."
Answer: 4 The client is experiencing a spontaneous abortion (miscarriage), which cannot be prevented and will terminate her pregnancy. Bed rest will not reverse this process.
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1. Monitor for fetal movement. 2.Monitor the maternal blood glucose. 3.Instruct the client to maintain complete bed rest. 4.Instruct the client to restrict dietary sodium and any food items that contain sodium.
Answer: 1 A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary.
The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources for which primary reason? 1. Reduce excessive maternal stress and fatigue. 2.Help the mother prepare for labor and delivery. 3.Avoid exposure to potential pathogens and resulting infections. 4.Prepare the 18-month-old child for maternal separation during hospitalization.
Answer: 1 A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The use of resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. These resources are not intended to minimize potential risk of maternal infection or prepare the client and family for the subsequent labor, delivery, and hospitalization.
The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding? 1. Fundus is at the appropriate level. 2. Fundus is larger than expected height. 3. Fundus is smaller than expected height. 4. Growth pattern indicates intrauterine growth restriction (IUGR).
Answer: 1 At the previous routine visit at 20 weeks' gestation, the fundus was located at the umbilicus. For each subsequent week after 20 weeks, fundal height should increase by approximately 1 cm/week. At 24 weeks' gestation, the appropriate fundal height would be 24 cm plus or minus 2 cm. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process.
The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. 1. Viruses 2.Bacteria 3.Nutrients 4.Antibodies 5.Medications
Answer: 1,3,4,5 Large particles such as bacteria cannot pass through the placenta, but viruses, nutrients, medications, antibodies, and recreational drugs can pass through the placenta and potentially affect the fetus. Metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them.
A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction? "I should wear flat-heeled shoes." 2."I should sleep on a firm mattress." 3."I should try to maintain good posture." 4."I should do more exercises to strengthen my back muscles."
Answer: 4 Some measures that will assist in relieving a backache include maintaining good posture and body mechanics, resting and avoiding fatigue, wearing flat-heeled shoes, and sleeping on a firm mattress. The back discomfort that occurs in a pregnant client is often caused by the exaggerated lumbar and cervicothoracic curves resulting from a change in the center of gravity because of the enlarged uterus. Performing more exercises to strengthen the back muscles could be harmful to a pregnant client.
A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms? 1. Eating a high-fat diet 2.Increasing fluids with meals 3.Eating a high-carbohydrate diet 4.Eating dry crackers before arising
Answer: 4 Some strategies for decreasing morning nausea are keeping crackers, Melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats; and consuming adequate fluid between meals but not with meals. A high-carbohydrate diet could increase the episodes of nausea.
