Maternity C
The nurse instructs a client in the second trimester at the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client makes which statement? A. "I will add one nutrient dense 300 calorie snack per day." B. "I will follow the Ketogenic diet to be sure I don't gain too much weight." C. "I will increase my intake of coffee per day, as I don't like water." D. "I will increase my caloric intake by adding one bag of potato chips and 16 oz of cola per day."
A. "I will add one nutrient dense 300 calorie snack per day." Explanation: During pregnancy the recommended dietary allowance (RDA) increases by 300 calories per day more than pre-pregnancy needs. An increase in maternal caloric intake is most important during the second and third trimesters. B. The Ketogenic diet is very restrictive; not allowing the pregnant mother to consume many vegetables and fruit, while consuming foods high in protein and fat. Although protein is necessary for tissue growth and repair, only a modest increase of protein is required. C. Water is necessary for all body tissues and all body system functions. During pregnancy, blood volume increases about 1,500 ml (40-50% increase from pre-pregnancy blood volume). Because of this increase in blood volume, the pregnant woman should increase her water intake of 8-10 8 oz. glasses of fluids per day. Increasing coffee intake will cause dehydration as it acts as a diuretic. D. These options are all empty calories and offer no nutrients to client. The client needs to understand the essential nutritional elements in order to modify her diet for the developing fetus and her own nutritional maintenance.
The nurse teaches a class about gonorrhea. Which client statement indicates the teaching is successful? A. "I've heard that having gonorrhea can make you unable to have children." B. "They say this disease can affect your brain and make you go crazy." C. "I've heard you can't get rid of gonorrhea. You keep getting it over and over again." D. "My parent said you need to have cesarean deliveries after this infection."
A. "I've heard that having gonorrhea can make you unable to have children." Explanation: Gonorrhea causes pelvic inflammatory disease, which is one of the most common causes of sterility. Gonorrhea is treated with antibiotics. B. There is central nervous system involvement that occurs with late SYPHILIS, not gonorrhea. C. The client should avoid sexual activity until infection is cured. D. Gonorrhea may cause preterm labor, premature rupture of membranes, or postpartum endometritis. It may also cause sepsis, conjunctivitis, or preterm birth in the infant.
The nurse instructs a group of expectant clients on how to recognize the onset of labor. The nurse knows FURTHER TEACHING IS NECESSARY if a client makes which statement? A. "My baby will move more when I go into labor." B. "I may feel a gush of water at the beginning of labor." C. "I may have blood-tinged vaginal discharge." D. "I will have regular uterine contractions that become stronger."
A. "My baby will move more when I go into labor." Explanation: Fetal movement remains unchanged up to the start of labor and in early labor. As labor progresses movement is generally felt between contractions, although the baby may continue to move during contractions. B. This indicated ruptured membranes. Labor usually begins within 24 hours of spontaneous rupture of membranes. If the client experiences spontaneous rupture of the amniotic sac, the client should take note of the color, amount, and odor of the amniotic fluid. Urinary incontinence is sometimes confused with ruptured membranes; a nitrazine tape test should be conducted to be sure. C. This is describing bloody show. This is one of the signs of preceding labor. During pregnancy the cervix is plugged with mucus. This mucus plug acts as a protective barrier for the uterus and its contents throughout the pregnancy. As the cervix begins to soften, stretch, and thin through effacement, there may be rupture of the small cervical capillaries. The presence of bloody show often indicates that labor will begin within 24 to 48 hours. D. This indicates true labor. Discomfort radiates from back around to abdomen, and contractions do not decrease with rest. During true labor the cervix progressively effaces and dilates.
The nurse in the emergency department provides care for a client at 29 weeks gestation reporting vaginal bleeding. The nurse identifies the client statement as indicative of a placenta previa? A. "The bleeding scares me, other than that I feel fine." B. "I've been more nauseated during the past few weeks." C. "The bleeding started after I carried in four bags of groceries." D. "I've been having severe abdominal cramps."
A. "The bleeding scares me, other than that I feel fine." Explanation: Painless vaginal bleeding indicates placenta previa. Placenta previa is a placenta that is abnormally implanted in the lower uterine segment. The client will be treated with bedrest and intravenous fluids to restore blood volume. The nurse should ensure no vaginal exams are performed and monitor fetal well-being. B. Nausea is not associated with placenta previa. C. The bleeding of placenta previa is not related to activity. It is due to disruption of a placenta that is implanted over or close to the cervical os. D. Painful vaginal bleeding indicates abruptio placenta, the premature separation of a normally implanted placenta.
The nurse provides care for a primigravida client who is 34 weeks pregnant. Which client statement is of MOST concern to the nurse? A. "This is not a good time for me to have a baby." B. "I'm afraid labor will hurt." C. "Sometimes I get tired before evening comes." D. "My feet swell, especially in the evening."
A. "This is not a good time for me to have a baby." Explanation: This statement may indicate the client still has not accepted the pregnancy. Ambivalence or unhappiness about the pregnancy that continues into the third trimester may suggest the client will have difficulty accepting the baby. The nurse should explore this further. Parent-child bond is a strong emotional and physical bond between parent and baby after personal contact. It is usually done within hours of birth and it is essential that this contact occur as soon as possible after birth and for as long as possible. B. Fear of pain during labor is a normal concern for a primigravida in the third trimester. C. It is normal for a woman in the third trimester of pregnancy to be tired at the end of the day. D. It is normal for feet to swell in the third trimester of pregnancy. Swollen hands or face would be of greater concern to the nurse as that could indicate gestational hypertension.
The nurse provides care for a client in labor. The client's labor progresses with regular contractions until the cervix is 9 cm dilated. The nurse identifies the client is in which stage of labor? A. First stage. B. Second stage. C. Third stage. D. Fourth stage.
A. First stage. Explanation: From the beginning of labor until the cervix is completely dilated is the first stage, commonly referred to as the stage of dilation. This stage is divided into phase 1 (latent, 0-3 cm), phase 2 (active, 4-7 cm), and phase 3 (transition, 8-10 cm). B. The second stage is from complete dilatation to the birth of the baby. This stage is also separated into phase 1, 0 to +2 station; phase 2, +2 to +4 station; and phase 3, +4 to birth. C. This stage is from the birth of the infant to the complete delivery of the placenta. This stage generally lasts 5-10 minutes, but can last up to 30 minutes. The umbilical cord descends further through the vagina followed by a gush of blood as the placenta detaches from the uterus, then the placenta is delivered. D. The fourth stage is the period of maternal physiological adjustment that occurs from the time of delivery of the placenta through the first 1 to 2 hours after birth. This stage involves careful monitoring and assessments of both the mother and the infant.
The nurse provides care for a client in labor. The nurse is MOST concerned the fetus is experiencing distress if which heart rate pattern is observed? A. Late decelerations. B. Early decelerations. C. Irregular heart rate. D. Variable deceleration.
A. Late decelerations. Explanation: A fall in fetal heart rate after the peak of the contraction with a gradual return to baseline. These usually mirror contractions, and do not resolve until the contraction ends. Late decelerations indicate the presence of uteroplacental insufficiency, a decline in placental function. Normally the fetus can withstand repeated contractions with sufficient oxygenation. However, in this circumstance a decrease in blood flow from the uterus to the placenta results in fetal hypoxia, and decelerations are seen on the monitor. Position the client on the left side, administer oxygen by mask, start IV or increase flow rate, and stop oxytocin if appropriate. B. Early decelerations are indicated by a fall in fetal heart rate prior to the peak of contraction. Early decelerations are considered benign and are usually well tolerated by the fetus. These are thought to indicate fetal head compression. C. Moderate fetal heart rate variability indicates fetal well-being. D. These can occur at any time during the contraction, and are the most common deceleration pattern seen in labor. They are ominous if repetitive, prolonged, severe, or slow return to baseline. Variable decelerations are thought to indicate umbilical cord compression.
A client receives magnesium sulfate intravenously for treatment of preeclampsia. The client's assessment reveals: BP 110/70 mm Hg, P 98 beats/minute, R 11 breaths/minute, hyporeflexia, anda urine output of 20 mL/hr. Which analysis by the nurse is BEST? A. Maternal toxicity has occurred. B. An additional dose of magnesium sulfate s needed. C. Desired systemic results have been reached. D. Drug therapeutic levels have been attained.
A. Maternal toxicity has occurred. Explanation: Toxic levels of magnesium sulfate have been reached when respirations are fewer than 12/min, urine output is less than 25 mL/hr, or reflexes are slowed or absent. Magnesium balance is crucial to neuromuscular function with a normal range of 1.5 to 2.5 mEq/L (0.75 to 1.25 mmol/L). Hypermagnesemia occurs when levels are greater than 2.5 mEq/L (1.25 mmol/L). Symptoms include hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, paralysis, and shallow respirations. Causes include acute kidney injury and excessive magnesium administration. Treatment includes discontinuing oral and intravenous (IV) magnesium, supporting ventilation, administering IV calcium gluconate, and hemodialysis if needed. Nursing considerations include monitoring reflexes, teaching about over-the-counter drugs containing magnesium, monitoring cardiac rhythm, and having calcium preparations available to antagonize cardiac depression. B. Another dose of the medication in this situation could cause cardiac arrest, total paralysis, or death. C. Desired results are increased urinary output and the preventions of convulsions. The client's data indicates that toxic levels of magnesium sulfate have been reached. D. This data does not support the fact that therapeutic levels have been attained, but rather toxic levels have been reached.
The nurse provides postnatal care for a client diagnosed with gestational diabetes who delivered by cesarean delivery at 37 weeks gestation about 3 hours ago. The infant's Apgar scores were 6 and 8 and birth weight 10 lbs (4535.9 g). The client tells the nurse, "I can't believe how big my baby is, and I even delivered early." Which response by the nurse is BEST? A. "You need to ask your parents if you were also a large baby at birth." B. "The baby's large size is due to the amount of glucose received in utero." C. "It is great that you are starting to rely on your maternal instinct already!" D. "You must be relieved that the baby looks so chubby and healthy."
B. "The baby's large size is due to the amount of glucose received in utero." Explanation: Fetal macrosomia of insulin-dependent diabetic mothers is caused by poor maternal glucose control. Fetal macrosomia, birth weight greater than 8 lb 13 oz regardless of gestational age, is more likely to be a result of maternal diabetes, obesity, or weight gain during pregnancy than other causes. The infant has a round face, chubby body, and a flushed complexion. The infant at risk for hypoglycemia, hypocalcemia, and hyperbilirubinemia soon after birth. A. Heredity can be a factor in large gestational age (LGA) infants, but this infant's size is more likely due to glucose intolerance of pregnancy. C. This response does not address the situation. The infant's large size is likely related to the gestational diabetes. The infant requires frequent assessment for hypoglycemia and for respiratory distress syndrome. D. The nurse is not addressing the client's statement appropriately. The nurse should use the client's statement to discuss the care and monitoring the infant will require in the postpartum period.
A client is admitted to the hospital and is scheduled to have a modified radical mastectomy. The client asks the nurse about the surgical procedure. Which explanation does the nurse give? A. "Only the tissue is removed, leaving all the muscles and lymph nodes." B. "The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved." C. ""The breast, axillary nodes, and the major and minor pectoral muscles are preserved." D. "The sternum will be split and the lymph nodes will be dissected from the mediastinum."
B. "The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved." Explanation: In a modified radical mastectomy, the breast, axillary nodes, and superior apical nodes are removed, but the major and minor pectoral muscles are preserved. A. A total (simple) mastectomy is removal of the entire breast with the lymph nodes left intact. C. This describes a lumpectomy. D. This is not a procedure for breast cancer.
The nurse provides care for a 4 lb 10 oz (2100.13 g) infant delivered at 32 weeks gestation. The nurse notes the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The nurse recognizes these findings are signs of which problem? A. Respiratory distress syndrome. B. Cold stress. C. Perinatal asphyxia. D. Hypovolemia.
B. Cold stress. Explanation: In response to excessive loss of heat, the neonate's body responds with increased respirations and non-shivering thermogenesis. Cold stress results in increased metabolic rate and oxygen consumption, and if left untreated, can increase the risk of mortality. Neonates are prone to rapid heat loss and consequent hypothermia because of a high surface area to volume ratio, which is eve higher in low-birth weight neonates. Metabolic and respiratory acidosis occurs. Signs of cold stress include mottled skin, tachypnea, bradycardia, weak cry, and poor feeding. The nurse should rewarm the neonate in an incubator or under a radiant warmer and treat any underlying conditions. A. Respiratory distress syndrome is an altered respiratory state due to surfactant deficiency in the lungs. The infant will develop labored respirations after several initial minutes or hours of normal respirations. Other signs of respiratory distress syndrome are cyanosis, grunting, nasal flaring, retractions, and tachypnea. C. Perinatal asphyxia occurs in utero, typically in a fetus that is small for gestational age (SGA) and with a maternal history of heavy cigarette smoking. The nurse should prepare for aggressive ventilatory assistance. D. These signs and symptoms are suggestive for cold stress. The infant with hypovolemia would display hypotension, tachycardia, sunken fontanels, cold skin, and abnormal drowsiness.
The nurse provides care for a client receiving an oxytocin infusion to induce labor. The nurse stops the infusion if which occurs? A. Contractions are at 3 minute intervals and last 55 to 60 seconds. B. Contractions are at 2 minute intervals and last 90 to 120 seconds. C. Contractions are at 3 minute intervals and last for 80 to 90 seconds. D. Contractions are at 2 minute intervals and last 60 to 90 seconds.
B. Contractions are at 2 minute intervals and last 90 to 120 seconds. Explanation: An adverse effect of the use of oxytocin to induce labor is uterine hyperstimulation, a serious complication of labor induction. Hyperstimulation is defined as single contractions lasting longer than 90 seconds, or five or more contractions in a 10 minute period (less than 2 minutes of rest between contractions). It can cause impairment to uteroplacental blood flow and result in fetal heart rate abnormalities, fetal hypoxia, and fetal damage. It is extremely important for the nurse to continually assess contractions for the client receiving an oxytocin infusion. If the client exhibits uterine hyperstimulation, the nurse should stop the infusion and notify the health care provider. A. This is an acceptable rate for contractions during induction with oxytocin. The contractions are at 3 minute intervals lasting 60 seconds. There should be at least 2 minutes of rest between contractions. C. This is acceptable, but the nurse should monitor carefully. The contractions are lasting 90 seconds and should not be sustained longer than that. D. The nurse should stop the infusion if contractions last more than 90 seconds or becomes more frequent than every 2 minutes.
The nurse provides care for a client in the second stage of labor. The nurse notes the client is tiring after a few hours of pushing, and is no longer making progress. Which does the nurse anticipates the health care provider will ask for? A. An infusion of oxytocin. B. Forceps or vacuum. C. An infusion of magnesium sulfate. D. The OR to be prepped for a cesarean section.
B. Forceps or vacuum. Explanation: Forceps or vacuum-assisted births occur when the client is incapable of pushing with contractions due to exhaustion and/or spinal or epidural anesthesia as well as fetal distress, and potential for maternal complications. There are many risks with forceps-assisted births, so vacuum extraction is preferred. Little anesthesia is required and is associated with fewer lacerations of the maternal birth canal. Both require the fetal scalp to be visible on the maternal perineum, ruptured membranes, and absence of cephalopelvic disproportion. A. Oxytocin, also known as pitocin, is used to cause contraction of the uterus to start labor, increase speed of labor, and to stop bleeding following delivery. It would be helpful with an exhausted client during the second stage of labor. C. Magnesium sulfate is used to reduce seizure risks in preeclamptic clients and can also be used to prolong pregnancy for two days. This would not be administered at this time. D. Unless previously scheduled by the client and health care provider, cesarean births are only performed when the health of the mother or her fetus is jeopardized. As this is a major surgical procedure that carries many risks and complications, other methodologies should be utilized before calling in the OR team.
While in active labor, the multigravid client received magnesium sulfate for treatment of gestational hypertension. Due to the effects of magnesium sulfate, which newborn symptom is expected? A. Bradycardia. B. Hypotonia. C. Tachypnea. D. Hypertension.
B. Hypotonia. Explanation: The magnesium sulfate crosses the placenta and causes hypotonicity in the neonate. Magnesium sulfate is an anticonvulsant when given intravenously (IV), saline cathartic when given orally, or an electrolyte replacement agent. Adverse effects include weak or absent deep tendon reflexes, hypotension, respiratory paralysis, depressed cardiac function, and hypocalcemia. Nursing considerations include checking respirations before giving medication IV (Should be over 16 per minute), testing knee jerk and patellar reflexes each dose, and monitoring vital signs, intake, and output. A. Magnesium sulfate would cause a rapid heart rate in the neonate. C. Magnesium sulfate would cause respiratory depression in the neonate. D. Hypertension is not a neonatal effect of magnesium sulfate.
The nurse explains to a client that which period of pregnancy is the most critical time for fetal development? A. The first two weeks. B. The first three months. C. The fourth through the sixth month. D. The last month.
B. The first three months. Explanation: It is during the first trimester, the embryonic period, that all the major systems of the fetus are developed. The three germ layers form that later develop into tissues and organs, as well was the early development of the nervous system, cardiovascular system and the major internal and external structures. Exposure of mother to noxious environmental agents can interfere with proper development of fetal organs and body systems. A. The pre-embryonic stage lasts from conception to 14 days. Rapid cellular multiplication, cell differentiation, and the establishment of the embryonic membranes and primary germ layers occur during this time. This is not the most critical time for fetal development. C. All body systems are already developed at this time. D. The fetus increases in weight the last month. At 36 weeks the fetus may be able to adjust to extrauterine life.
During auscultation of the fetal heart rate (FHR) during labor, the nurse assesses a rate of 59 beats/minute. Which actions does the nurse take FIRST? A. Turns the client on the right side, opens the IV line, and calls the health care provider. B. Turns the client on the left side, administers oxygen by nasal cannula, and verifies IV access. C. Places the client in semi-Fowler's position, provides ice, and calls the health care provider. D. Places the client in Trendelenburg position, administers oxygen, and forces fluids.
B. Turns the client on the left side, administers oxygen by nasal cannula, and verifies IV access. Explanation: The normal fetal heart rate should be between 110-160 beats/minute. Bradycardia indicates fetal distress. Persistent bradycardia may indicate cord compression or separations of the placenta. The nurse should turn the client to the left side to maximize blood flow to the placenta, provide the client with oxygen, and ensure there is IV access if needed. A. Positioning the client on the left side promoted better blood flow to the uterus due to less compression of the inferior vena cava. C. These actions would not alleviate fetal distress. The nurse should notify the health care provider after implementing actions to alleviate the fetal distress. D. Trendelenburg would increase the pressure on the vena cava, which would decrease blood return. This would be contraindicated for this client.
The nurse provides care for a client in labor to deliver twins. For which complication does the nurse identify that this client is at higher risk? A. Precipitate labor. B. Uterine dysfunction. C. Placenta previa. D. Eclampsia
B. Uterine dysfunction. Explanation: Uterine dysfunction and premature separation of the placenta may occur more commonly with multifetal pregnancy. The first stage of labor is divided into three phases; phase one (latent) where the cervix is dilated 0 to 3 cm and contractions are 10 to 30 seconds long, 5 to 30 minutes apart. Phase two (active) consists of the cervix dilated 4 to 7 cm, contractions are 30 to 40 seconds long, 3 to 5 minutes apart, and are moderate to strong. Phase three (transition) where the cervix is dilated 8 to 10 cm, contractions are 45 to 90 seconds long, 2 to 3 minutes apart, and strong, impending delivery marked by increase in dark red bloody show and increased urgency to bear down. A. Precipitous delivery is not necessarily limited to multifetal births. C. Placenta previa is not increased in clients with twins. D. There is indication of symptoms of eclampsia.
The home health care nurse makes a visit to the pregnant client diagnosed with type 1 diabetes mellitus. The client states, "I have been nauseated for 24 hours." It is MOST important for the nurse to ask which question? A. "Have you vomited?" B. "What was your last blood sugar reading?" C. "Have you taken your insulin today?" D. "When did you last eat?"
C. "Have you taken your insulin today?" Explanation: It is important that the client take prescribed insulin even when not eating regularly because insulin needs are increased during illness. The nurse should review "sick day rules" with the client. Even without oral intake, stress hormones can increase blood glucose levels. The client with a diagnosis of type 1 diabetes may become extremely hyperglycemic without taking adequate insulin. A. The nurse does not need to determine symptoms; however, it is more important that the client is taking insulin. B. It is appropriate to determine the current glucose reading. However, this is not the priority. D. The nurse should inquire about oral fluid intake in order to prevent dehydration. However, the time of last intake of food is not a priority.
The nurse provides instruction to a new parent on how to care for the newborn's umbilical cord. The nurse determines teaching is effective if the parent makes which statement? A. "I am going to bathe my baby in the new tub tomorrow." B. " I will keep the cord covered with the diaper." C. "I will clean the cord and the skin around it with water." D. "I will allow the cord to fall off on its own." E. "I will expect some redness and discharge at the cord site." F. "I will apply petroleum jelly to the base of the cord."
C. "I will clean the cord and the skin around it with water." D. "I will allow the cord to fall off on its own." Explanation (C): The parent should be instructed to clean the cord and surrounding area with water or a solution preferred by the health care provider, and to report redness, drainage, or foul odor. Explanation (D): The parent should not pull the cord off when it becomes loose, but should let the cord fall off on its own. A. The baby should not have tub baths until the cord falls off. B. The parent should fold the diaper below the umbilicus to maintain a dry area. E. The parent should report any redness, drainage, or foul odor from the site to the health care provider. F. The parent should cleanse the cord with water and observe the base of the cord for edema, redness, and purulent drainage. The parent should not apply petroleum jelly or any other substance to the cord.
The nurse assesses a client in the family planning clinic. Which client statement suggests the client has been exposed to gonorrhea? A. "My partner has a sore on the penis." B. "I have a cheesy, white vaginal discharge." C. "My partner has the drip." D. "I have a rash."
C. "My partner has the drip." Explanation: Men report urethritis and epididymitis and there may be a whitish-yellow or cloudy discharge-or "drip"- from the penis. Women are frequently asymptomatic. Gonorrhea can be diagnosed by culture of discharge from cervix or urethra. Common treatments include ceftriaxone and doxycycline. A. A sore on the penis indicates syphilis and presents as a painless chancre that fades after 6 weeks. Syphilis is diagnosed by the Venereal Disease Research Laboratory test (VDRL). Treatment includes penicillin or erythromycin. B. Cheesy, white vaginal discharge is indicative of candidiasis. Other symptoms include vulvar and vaginal pruritus. Treatment options include an antifungal medication. D. Syphilis can cause a copper-colored rash on palms and sores.
The nurse instructs a client about dietary adjustments that may be necessary during breastfeeding. Which client statement indicates to the nurse that the client understands the instructions? A. "Dietary changes that enhance weight loss are acceptable." B. "I must drink milk to make milk." C. "There are no specific restrictions on food or drinks." D. "Herbal teas are recommended to enhance milk supply."
C. "There are no specific restrictions on food or drinks." Explanation: There are no specific food or drink restrictions. The breastfeeding client must remember that the diet should have adequate calories, protein, and water soluble vitamins like C and B6. Much of what is ingested passes through breast milk. The mother is instructed that most drugs cross into breast milk and the mother should check with the health care provider before taking any medications. A. It is not recommended that breastfeeding clients lose large amounts of weight. In order to provide adequate nutrients for the baby, an increase of 200 to 500 calories is often recommended in the breastfeeding client's diet. B. A breastfeeding client does not need to drink milk to make milk. However, adequate calcium and phosphorous are needed in the diet, as well as increased fluid volume to avoid depleting her own body stores and avoid constipation. D. Often, herbal teas are medicine and may enter the infant through the breast milk and adversely affect the infant.
The nurse makes a home visit to a postpartum client and the two-week-old infant. The client is breastfeeding and tells the nurse the baby nurses 8-9 times per day, has regained all of the lost baby weight, has 6-8 wet diapers per day, and usually has one bowel movement per day. Which response by the nurse is BEST? A. "Your baby should be gaining more weight." B. "The baby should have at least 3 bowel movements per day." C. "Your baby is doing well. Keep up the good work!" D. "The baby should not need to nurse that frequently."
C. "Your baby is doing well. Keep up the good work!" Explanation: The infant has regained the initial weight loss. A well-hydrated infant should have 6-8 wet diapers per day. The nurse should record results in the client record and provide the client with positive feedback. A. The infant has regained the initial weight loss within 14 days. B. One to three bowel movements per day is normal. D. A newborn infant should breastfeed at least 8 times per day.
The nurse provides care for a client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen minutes later the nurse notes the perineal pad is soaked and there is blood underneath the client's buttocks. Which action does the nurse take first? A. Obtains the client's blood pressure. B. Notifies the health care provider. C. Assesses the fundus. D. Administers oxygen at 8-10 L/min.
C. Assesses the fundus. Explanation: The nurse needs to assess for uterine atony. The nurse may need to start intravenous fluid replacement and may need to administer oxytocin if the client's fundus does not respond to fundal massage. A. Perineal pads socked in less than 15 minutes or pooling of blood under the client's buttocks indicates excessive bleeding. Blood pressure is not a reliable indicator of impending shock due to early hemorrhage. B. The nurse needs to intervene for possible uterine atony before notifying the health care provider. D. Supplemental oxygen may be needed if the client continues to experience uterine atony and bleeding.
A client is pregnant for the third time. The client has one living child and has had one abortion. Which description does the nurse record? A. Gravida III, para II. B. Gravida II, para II. C. Gravida III, para I. D. Gravida II, para III.
C. Gravida III, para I. Explanation: The client is experiencing the third pregnancy (gravida III), but in only one pregnancy did the fetus reach the age of viability (para I). Should the client carry this fetus to term and deliver the baby live, it will be Gravida III, para II. A. Gravida denotes the number of pregnancies, para describes live births. As the client has only had one live birth, para is described incorrectly. B. Gravida is recoded wrong in this case, as the client has been pregnant three times. D. Gravida and para are both expressed wrongs this is incorrect.
By the fifth month of pregnancy, a 32-year-old multipara client of average prenatal height and weight has gained 14 pounds. Which action by the nurse is MOST important? A. Advise the client too much weight has been gained and the diet should be reevaluated. B. Advise the client not enough weight has been gained and the diet should be reevaluated. C. Inform the client the weight gain is appropriate and the present diet should be maintained. D. Inform the client difficulties may occur later in pregnancy and more frequent visits to the health care provider are indicated.
C. Inform the client the weight gain is appropriate and the present diet should be maintained. Explanation: A 14-lb weight gain during the first 5 months of pregnancy is appropriate. The client should gain 2 to 4 lbs during the first trimester and then approximately 1 lb per week until birth. A 12 to 16 lb weight gain at this point would be appropriate. A. This weight gain is appropriate. During the first trimester it is appropriate to gain 2 to 4 lbs. During the second and third trimester it is appropriate to gain 1 lb/week. Underweight women will need to gain more, while overweight women will need to gain less. B. For an average weight and size person, this weight gain is appropriate. D. There is not an increased number of difficulties during this time in pregnancy. Frequent health care provider visits are indicated due to increased monitoring for the onset of labor.
The nurse provides care for a newborn delivered by a client addicted to narcotics. At which time is the nurse MOST likely to observe symptoms of narcotic withdrawal? A. Immediately at birth. B. Within 12 hours after birth. C. Within 24-72 hours after birth. D. Two weeks after birth.
C. Within 24-72 hours after birth. Explanation: Symptoms of neonatal abstinence syndrome (NAS) include tremors, loud pitched screams, trouble breathing, sweating, fever, and the inability to eat. Most of these symptoms begin 24 to 72 hours after birth and can last up to five days. A. This is too soon. The client may have taken narcotics immediately prior to admission to the hospital. B. Neonatal withdrawal from narcotics is observed 24-72 hours after birth. D. If the client is taking methadone, the infant usually demonstrates signs of withdrawal about 7 days after birth.
The nurse counsels clients in the prenatal clinic. The nurse is MOST concerned if a client makes which statement? A. "I take my dog for a 30-minute walk every other day." B. "I plan to take an 8-hour car trip next week." C. "I drink 3 liters of liquids every day." D. "I clean the cat's litter box daily."
D. "I clean the cat's litter box daily." Explanation: This is concerning as the client could contract toxoplasmosis (protozoan infection). Toxoplasmosis is caused by eating infected undercooked meat or after handling infected kitty litter. Infection can cross the placenta and infect the fetus. The pregnant client should not clean the litter box, but if unavoidable, the client should wear latex gloves and wash hands well afterward. A. Regular exercise (at least 3 times per week) improves circulation and promotes relaxation and rest. B. Although there is potential for the client to develop a DVT on a long trip, it is not concerning. The client should be educated to wear a lab belt with shoulder harness to prevent injury. As well as practice deep breathing, foot circling, and isometric exercises while sitting in the vehicle. C. UTIs are common during pregnancy. It is best to encourage 2-3 L of liquid daily to ensure frequent urination.
The nurse assesses the fundus of a client 12 hours after delivery of a 7 lb 2 oz (3,240 g) newborn. Which action should the nurse take if the fundus is noted to be approximately 1 cm above the umbilicus? A. Encourage the client to void. B. Assess for the amount and character of the lochia. C. Bring the infant to the client for breastfeeding. D. Document the results in the client's record.
D. Document the results in the client's record. Explanation: The fundus is about at the umbilicus or 1 cm above the umbilicus within 12 hours of the birth. After this time, it should descend 1-2 cm each day. This is a normal finding and the nurse should document in the client's medical record. A. The nurse should assess for bladder distention prior to suggesting that the client needs to void. The fundus location does not indicate a distended bladder. B. The lochia should be bright red and less than a heavy menstrual period at this time. If the fundus was boggy or did not respond to massage, the nurse would be concerned the client could experience heavy bleeding. C. Nursing the infant will cause the uterus to contract due ti oxytocin stimulation. This would be an appropriate action to take if the uterus is relaxed and boggy when assessed.
A client comes to the hospital in labor. The membranes rupture at 0410. Which action does the nurse take FIRST? A. Identifies the amniotic fluid by performing a nitrazine tape test. B. Contacts health care provider and prepares for immediate delivery. C. Documents admission and notes the time of rupture of membranes. D. Observes the amniotic fluid for any signs of infection or meconium.
D. Observes the amniotic fluid for any signs of infection or meconium. Explanation: It is important to note the color, amount, and odor of the amniotic fluid. The fluid should be clear and odorless, and may contain white specks (vernix caseosa) and fetal hair. A yellow-green tinged amniotic fluid may indicate infection or fetal passage of meconium. Which could be possibly have life-threatening complications to the fetus that may require emergency delivery. A. The client is in active labor, a nitrazine tape test is not needed at this stage. A nitrazine tape test would be performed if the client was unsure of whether it was urine incontinence or ruptured membranes. B. This is expected during labor, the nurse would not need to prepare for immediate delivery. The health care provider would need to be told that labor is progressing, however this is not an emergent notification. C. The nurse should not and document admission and time of rupture, but it is most important to assure fetal well-being.
The nurse provides care for a client in active labor who is 6 cm dilated. The client is now ready for epidural anesthesia. Which position will the nurse assist the client? A. Modified knee-chest with upper leg flexed and lower leg extended. B. A sitting position with back straight and feet supported on a stool. C. Prone position, head on arms, and pillow at pelvic area. D. On the left side, shoulders parallel, legs flexed, and back arched.
D. On the left side, shoulders parallel, legs flexed, and back arched. Explanation: This position best exposes the vertebrae to the anestheist and allows entry into the epidural space. Epidural anesthesia: a spinal anesthetic is a local anesthetic injected into the lumbar intervertebral space beyond the dura mater into the subarachnoid space and blocks pain sensations only (not movement). Complications of regional anesthesia include blocking of sympathetic nerve fibers and hypotension caused by loss of vasoconstrictor ability. Nursing care includes pre-hydrating before administering a regional anesthetic to ensure adequate blood pressure and fetal heart rate (FHR) frequently. If the client becomes hypotensive, place in left lateral position, increase rate of IV fluids, administer oxygen by mask, and notify the health care provider. A. This position is used for the administration of caudal anesthesia through the sacral hiatus. B. This position is used for the administration of spinal anesthesia, in which the anesthetic is injected into the subarachnoid space. The back should be arched, not straight. C. This position, lying face downward, would be very difficult to assume during labor and could have undesirable effects on the mother and fetus.
