Maternity-Physiological Adaptation

The family of a pregnant client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the best response by the nurse?

"The progression is slow, so people with myasthenia will spend their younger life with few problems." Rationale: The correct response is as optimistic as is possible while still being realistic. Stating that medications will mask the signs of the disease constitutes false reassurance; the client's status will depend on individual response. Medication does not affect progression of the disease; it only treats the adaptations. Stating that there will be periods when bedrest will be necessary and times when regular activity will be possible constitutes false reassurance; individual responses vary.

A 16-year-old primigravida at 36 weeks' gestation visits the prenatal clinic for a routine examination. Her blood pressure is significantly increased, and there is 1+ proteinuria. The client's blood pressure had been averaging 92/70 mm Hg during her previous prenatal visits. What is the lowest blood pressure that should cause the nurse to become concerned?

122/86 mm Hg Rationale: An increase of 30 mm Hg systolic and/or 15 mm Hg diastolic has been removed from the official definition of preeclampsia. The new definition encourages practitioners to consider the total situation in determining a diagnosis of preeclampsia. The proteinuria is a sign of mild preeclampsia; the increase in blood pressure should cause concern and warrant close monitoring. A mild increase is within the acceptable increase of blood pressure during pregnancy.

The nurse teaches a client that heart failure can best be described as:

An inability of the heart to pump blood in proportion to metabolic needs Rationale: As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop; the condition may be acute or chronic.

What change does a nurse expect in a client's hematologic system during the second trimester of pregnancy?

An increase in blood volume Rationale: The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks' gestation. The hematocrit decreases as a result of hemodilution. The sedimentation rate increases because of a decrease in plasma proteins. White blood cells count remains stable during the antepartum period.

A client has a colostomy after surgery for cancer of the colon. What postoperative nursing intervention maximizes skin integrity?

Apply stoma adhesive around the stoma and then attach the appliance Rationale: Stoma adhesive protects the skin and helps to keep the appliance attached to the skin. The appliance should be emptied when it is one third to one half full. Allowing one half inch between the stoma and the appliance is too much space; the enzymes in feces can erode the skin. Initially the nurse should change the appliance; self-care usually is instituted more gradually depending on the client's physical and emotional response to the surgery.

As the nurse is teaching a child's parents about celiac disease, the mother sighs and says, "My neighbor told me that I'll only need to monitor the diet until our child is 8 years old. I'm so relieved. You know how kids are about eating!" The nurse's response should be based on the fact that the:

Basic defect of celiac disease is lifelong. Rationale: The diet must continue to be followed because the child will always have an absence of peptidase; some variations in the diet may be allowed, but this should not be promised. Each phase of child development may have problems related to dietary management; follow-up care is needed to prevent crises. A restricted diet is never easy to follow, especially for a growing child. Gluten must be avoided for a prolonged period and perhaps indefinitely.

A client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. The nurse determines that the client has Raynaud's disease and not Raynaud's phenomenon because of the:

Bilateral involvement Rationale: Raynaud's phenomenon has unilateral involvement, whereas Raynaud's disease has bilateral involvement. Tingling sensation indicates return of blood flow and is characteristic of both Raynaud's phenomenon and Raynaud's disease. Skin color changes indicate blood return and are characteristic of both Raynaud's phenomenon and Raynaud's disease. Changes in skin temperature indicate lack of blood supply and are characteristic of both Raynaud's phenomenon and Raynaud's disease.

After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What assessment should the nurse document that will aid confirmation of the diagnosis?

Characteristics of stools Rationale: Because intussusception creates intestinal obstruction in which the intestine "telescopes" and becomes trapped, passage of intestinal contents is lessened; stools are red and look like currant jelly because of the mixing of stool with blood and mucus. Frequency of crying is a behavior is not specific to a diagnosis of intussusception. Accurate intake and output records are important, but they are not essential for confirming this diagnosis. Bowel sounds will not be affected significantly with intussusception.

A client has been admitted for an upper respiratory tract infection secondary to chronic obstructive pulmonary disease (COPD). The nurse should expect which findings when auscultating the client's breath sounds?

Coarse crackles Rationale: Coarse crackles and rhonchi most often are auscultated in COPD clients who have had an exacerbation. Clients would exhibit prolonged expiration, not prolonged inspiration. The client would not exhibit short, rapid inspiration. The client would not exhibit normal breath sounds.

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?

Controlling intraocular pressure Rationale: Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. Intraocular pressure is not affected by activity of the eye. Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.

A client has end-stage kidney disease and is receiving hemodialysis. During dialysis the client complains of nausea and a headache and appears confused. Operating on prescribed protocols, the nurse should:

Decrease the rate of exchange Rationale: These are signs and symptoms of disequilibrium syndrome, which results from rapid changes in composition of the extracellular fluid and cerebral edema; the rate of exchange should be decreased. Although increasing the rate of infusion may relieve the headache, it will not relieve the other adaptations or the cause of disequilibrium syndrome. Although administering an antiemetic may relieve the nausea, it will not relieve the other adaptations or the cause of disequilibrium syndrome. Discontinuing the procedure is unnecessary; reducing the rate of exchange should reduce the adaptations of disequilibrium syndrome.

A client who had a myocardial infarction experiences a noticeably decreased pulse pressure. The nurse determines that this is a possible indication of

Decreased force of contraction Rationale: A direct relationship exists between the systolic blood pressure and the force of left ventricular contraction. An increased blood volume is indicated by hypertension, not a decreased pulse pressure. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac efficiency.

A client is admitted to a medical unit with the diagnosis of acute kidney failure. The nurse reviews the client's laboratory data, performs a physical assessment, and obtains the client's vital signs. What should the nurse conclude the client is most likely experiencing?

Hyperkalemia Rationale: Damaged kidneys are unable to excrete potassium, resulting in hyperkalemia. Potassium, part of the sodium-potassium pump, is involved with muscle contraction. The clinical manifestations indicate hyperkalemia. The expected serum level of potassium is 3.5 to 5.5 mEq/L. Hyponatremia generally is not associated with acute renal failure; hyponatremia is associated with headache, muscle weakness, apathy, and abdominal cramps, not with an irregular pulse or diarrhea. The expected serum level of sodium is 136 to 145 mEq/L. With acute kidney failure the serum sodium may be normal, increased, or decreased. Hypouricemia will not occur, because serum uric acid is increased in clients with kidney failure. Hypercalcemia is not associated with the assessment data listed in the scenario. The expected serum calcium level is 9.0 to 10.5 mg/dL. The serum calcium level with acute kidney failure may be slightly decreased.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's:

Inability to maintain an optimal level of functioning Ratinoale: The onset of disabling illness will divert an older person's energies, making it difficult to maintain an optimum level of functioning. Irritability in response to deprivation is an expected response. Decreased ability to recall recent facts can result from the aging process and the change in environment; it is not as important as the loss of function. A gradual memory loss and some confusion are expected; a sudden memory loss is cause for alarm.

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider the most likely reason for this change?

Increased intravascular volume Rationale: As fluid is administered intravenously or retained by the kidneys, the intravascular fluid volume increases, resulting in increased preload and afterload. Increased, not decreased, afterload will cause an increase in the pulmonary artery wedge pressure. Afterload is the peripheral resistance against which the left ventricle must pump. A decreased heart rate will not increase pulmonary artery wedge pressure. After a pulmonary artery wedge pressure reaches 20 mm Hg, the stroke volume does not increase significantly.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested medications and complains of severe epigastric pain. The client has absent bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. The primary health care provider has been contacted. The nurse's next priority should be:

Keep the client nothing by mouth (NPO) in preparation for surgery Rationale: These are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may minimize the tachycardia and tachypnea that are related to pain and possible blood loss, keeping the client NPO is the priority. Keeping the client NPO in preparation for surgery is more important than asking about the presence of black, tarry stools or red stools. Although this question should be asked, knowing whether any red or black stools have been noted will not change the medical or nursing care of the client at this time. The adaptations are indicative of perforation and the priority is to prepare the client for surgery.

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply.

Lethargy, Muscle twitching Rationale: Lethargy results from anemia, buildup of urea, and vitamin deficiencies. Muscle twitching results from excess nitrogenous wastes. Extensive nephron damage causes oliguria, not polyuria. Hypotension does not occur; the blood pressure is within the expected range or elevated as a result of increased total body fluid. Metabolic, not respiratory, acidosis occurs because of the kidneys' inability to excrete hydrogen and regulate sodium and bicarbonate levels.

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply.

Nasal flaring, Sternal retractions, Grunting respirations Rationale: Nasal flaring occurs because of the stress of breathing; the flaring allows more air to enter the respiratory passages. Sternal retractions occur when accessory muscles of respiration contract during the stress of breathing. Grunting respirations occur as the glottis closes and reopens at the height of inhalation; this momentary closure of the glottis increases the time during which oxygen and carbon dioxide are exchanged in the alveoli. Newborns have irregular respirations with periods of apnea. Cyanosis of the hands and feet (acrocyanosis) is typical of all newborns at the time of birth. A heart rate of 160 beats/min is within the expected range of heart rates of healthy infants.

A nurse is assessing a malnourished client with a history of cirrhosis. The client is experiencing nausea, ascites, and gastrointestinal bleeding. The primary cause of the client's ascites is a decrease in:

Plasma protein to maintain adequate capillary-tissue circulation. Rationale: Malnutrition and liver damage lead to a reduced serum albumin level and failure of the capillary fluid shift mechanism, resulting in ascites. Vitamins are unrelated to ascites. Iron promotes hemoglobin synthesis, which is unrelated to cirrhosis. The sodium level usually is excessive with cirrhosis.

A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?

Potassium Rationale: Release of adrenocortical steroids (cortisol) by the stress of surgery causes renal retention of sodium and excretion of potassium. Although sodium may be depleted by nasogastric suction, retention by the kidneys generally balances this loss. Calcium and chloride are not depleted by surgery or urinary excretion.

A pregnant woman with a history of heart disease visits the prenatal clinic at the end of her second trimester. What does the nurse anticipate about the care she will need?

Prophylactic antibiotics at the time of birth Rationale: Prophylactic antibiotics are given to clients with heart disease to reduce their risk for bacterial endocarditis. A vaginal birth, with a shortened second stage and an assisted birth involving forceps or vacuum extraction, is preferred. The data do not indicate which class of heart disease the client has; if it is class I and there is no cardiac decompensation, activities may be restricted but bedrest is not necessary. Increasing the dosages of the client's cardiac medications may or may not be necessary; dosages are based on each individual's response to the stress imposed by pregnancy.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?

Remove the air that is present in the intrapleural space Rationale: Air rises and is removed via a tube inserted in the upper intrapleural space. Draining serosanguinous fluid from the intrapleural compartment is accomplished by the tube placed at the base of the lung; fluid flows toward the base via gravity. Permitting the development of positive pressure between the layers of the pleura will cause, not prevent, a pneumothorax. Medication will not be instilled into the intrapleural space in this situation.

Which clinical indicators does the nurse expect a client with Parkinson disease to exhibit? Select all that apply.

Resting tremors, Flattened affect, Slow voluntary movements Rationale: Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow, voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for signs that strangulation of the intestine may have occurred. What is an early sign of strangulation?

Sharp abdominal pain Rationale: Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia. Flatus is impeded by strangulation. Vomiting is persistent, not projectile. Decreased bowel sounds are not an early sign of obstruction; decreased bowel sounds occur after gas and fluid accumulate.

A nurse is caring for a client with a 25-year history of excessive alcohol use. What does the nurse expect the client's diagnostic results to reveal?

Small liver with a rough surface Rationale: Scar tissue that forms as cirrhosis causes the liver tissue to contract, making the liver small with a rough surface; little lumps are formed as scar tissue pulls the liver at certain points. The client has cirrhosis, which interferes with the formation of blood clots; bleeding tendencies are expected. The liver converts ammonia to urea; therefore, the blood ammonia level increases when the liver fails. The high fever with a generalized rash is a manifestation of a liver infection, not cirrhosis.

A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply.

Stasis ulcer, Brown discoloration Rationale: Stasis ulcers result from edema or minor injury to the limb; they frequently form over the medial malleolus (inner ankle). The release of iron from hemoglobin as erythrocytes disintegrate in tissue results in ferrous sulfide formation, causing darkening of the tissues. Necrotic tissue is associated with peripheral arterial disease. Ecchymosis is caused by bleeding. Diminished pulses are associated with peripheral arterial disease.

A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer?

Supplemental oxygen Rationale: Oxygen supports vital centers of the body while the cause of the problem is investigated. Although an intravenous morphine may be done eventually if the client is experiencing a myocardial infarction, it is not the initial action and requires a prescription. Endotracheal intubation is not implemented by a nurse. Later, endotracheal intubation may be necessary if the client experiences respiratory failure or obstruction. Although a sublingual nitroglycerin may be done eventually if the client is experiencing angina, it is not an initial action and requires a prescription.

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. This is necessary because:

There is damage above the sixth thoracic vertebra. Rationale: The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. For which clinical indicators associated with unresolved severe peripheral edema should the nurse assess the client?

Tissue ischemia Rationale: Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia. Proteinemia, contractures, and thrombus formation are not complications resulting from long-term edema.

A nurse is caring for pregnant clients in the high-risk unit. In what disorder is stimulation of labor contraindicated?

Total placenta previa Rationale: A total placenta previa requires a cesarean birth; early intervention helps ensure a healthy neonate and mother. Diabetes mellitus and mild preeclampsia are both complications that may necessitate early birth to ensure a healthy neonate and mother. Induction of labor is indicated if the fetus is at term because prolonged rupture of membranes can lead to maternal and/or fetal sepsis.