Maternity Ch. 11: Maternal Adaptation

Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks' pregnant. The nurse would expect this woman's heart rate to be approximately what?

85 bpm (During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per minute.)

Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to do what?

detect heart sounds with a Doppler (Fetal heart sounds are audible with a Doppler at 10 to 12 weeks' gestation but cannot be heard through a stethoscope until 18 to 20 weeks' gestation.)

A client who has just given a blood sample for pregnancy testing in the health care provider's office asks the nurse what method of confirming pregnancy is the most accurate. The nurse explains the difference between presumptive symptoms, probable signs, and positive signs. What should the nurse mention as an example of a positive sign, which may be used to diagnose pregnancy?

visualization of the fetus by ultrasound

A pregnant mother may experience constipation and the increased pressure in the veins below the uterus can lead to development of what problem?

hemorrhoids

The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?

montgomery glands (montgomery tubercles--secrete lubricant for the nipples)

The nurse is examining a woman who came to the clinic because she thinks she is pregnant. What data collected by the nurse are presumptive signs of her pregnancy? (three answers)

morning sickness amenorrhea breast changes

The nurse is preparing to teach a community class to a group of first-time parents. Which information should the nurse include concerning what the pregnant woman's partner may experience as a normal response?

physical symptoms similar to the mother

The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?

positive home pregnancy test

A client's menstrual period is two weeks late. She has been feeling tired and has had bouts of nausea in the morning. What classification of pregnancy symptoms is this client experiencing?

presumptive

A new mother voices concerns about breastfeeding her infant. The nurse would explain to the mother the two hormones that control lactation and letdown are what?

prolactin oxytocin

A pregnant client reports an increase in a thick, whitish vaginal discharge. Which response by the nurse would be most appropriate?

"This discharge is normal during pregnancy."

A client in her second trimester of pregnancy is anxious about the blotchy, brown pigmentation appearing on her forehead and cheeks. She also reports increased pigmentation on her breasts and genitalia. Which statement by the nurse is most appropriate?

"This is called facial melasma and should fade after the birth."

A new mother asks the postpartum nurse if her baby is getting enough nourishment from breastfeeding within the first 24 hours following birth. The nurse would provide her what information?

Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well.

A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client?

Have you been sexually active in the past 2 months? (The client is presenting with presumptive or subjective symptoms of pregnancy. Given her symptoms and age, asking about sexual activity is the most appropriate question.)

A 28-year-old client in her first trimester of pregnancy reports conflicting feelings. She expresses feeling proud and excited about her pregnancy while at the same time feeling fearful and anxious of its implications. Which action should the nurse do next?

Inform the client this is a normal response to pregnancy that many women experience.

A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition?

Place the client in the left lateral position. (The symptoms experienced by the client indicate supine hypotension syndrome. When the pregnant woman assumes a supine position, the expanding uterus exerts pressure on the inferior vena. The nurse should place the client in the left lateral position to correct this syndrome and optimize cardiac output and uterine perfusion.)

The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?

darkened breast areolae

A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?

fetal movement felt by examiner

During an examination, a client at 32 weeks' gestation becomes dizzy, lightheaded, and pale while supine. What should the nurse do first?

turn the client to her left side (As the enlarging uterus increases pressure on the inferior vena cava, it compromises venous return, which can cause dizziness, light-headedness, and pallor when the client is supine. The nurse can relieve these symptoms by turning the client on her left side, which relieves pressure on the vena cava and restores venous return.)

The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?

ultrasound picture of her fetus