NSG 333 Ch 12- Nursing Management During Pregnancy

The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is:

December 30 Explanation: Using Naegele rule, since the first day of the client's last menstrual period is March 23, 7 days are added leading to the 30th. Subtracting 3 months from March is December. Thus, December 30 is the estimated date of delivery.

A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her?

Health-seeking behaviors related to ways to relieve discomforts of pregnancy Explanation: Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.

A nurse is auscultating the chest of a client at 16 weeks' gestation. The nurse immediately notifies the health care provider about which finding?

heart rate 25 bpm above baseline Rationale: Heart rate typically increases by 10 to 15 bpm starting between 14 to 20 weeks of pregnancy. However, an increase of 25 bpm would be a cause for concern. A soft systolic murmur, clear breath sounds, and symmetrical chest movement are normal findings.

A pregnant woman needs an update in her immunizations. Which vaccination would the nurse ensure that the woman receives?

hepatitis B Rationale: Hepatitis B vaccine should be considered during pregnancy. Immunizations for measles, mumps, and rubella are contraindicated during pregnancy.

A pregnant woman is flying across the country to visit her family. After teaching the woman about traveling during pregnancy, which statement indicates that the teaching was successful?

"I'll get up and walk around the airplane about every 2 hours." Rationale: When traveling by airplane, the woman should get up and walk about the plane every 2 hours to promote circulation. An aisle seat is recommended so that she can have easy access to the aisle. Drinking water throughout the flight is encouraged to maintain hydration. Calf-tensing exercises are important to improve circulation to the lower extremities.

A nurse is teaching a pregnant couple about birth education. The nurse determines that the teaching was successful when the couple makes which statement?

"We'll know what to do to actively take part in our child's birth." Rationale: The primary focus of birth education is to provide information and support to clients and their families to foster a more active role in the upcoming birth. Some methods of birth education focus on pain-free childbirth. Information provided in birth education classes helps to minimize anxiety and provide the couple with control over the situation, but elimination of anxiety or total control is unrealistic.

The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best?

"At 36 weeks' gestation, the fundus is in the normal expected location." Explanation: The fundus grows to reach the umbilicus at 20 to 22 weeks and the xiphoid process of the sternum at 36 weeks. Therefore, this fundus is in the normal, expected location. After 36 weeks' gestation, lightening occurs and the fundus will drop ~4 cm below the xiphoid process. Once the fundus reaches the xiphoid process, it cannot go higher without severely compromising maternal respiratory efforts.

A nurse is conducting a class geared toward changes in early pregnancy and self-care items like perineal hygiene. A woman shares that she douches at least once a day since she has "so much discharge" from her vagina. Which response by the nurse is most appropriate at this time?

"During pregnancy, you should not douche because it can cause fluid to enter the cervix resulting in an infection." Explanation: Even if vaginal discharge seems excessive, douching is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix, leading to a uterine infection. In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth. Stating that douching will keep the client clean does not provide the client with the information she needs. Boiling water for a douche will not prevent development of infection. The nurse is capable of responding to the client directly without referring the client to the health care provider.

A nurse is working with a pregnant client to schedule follow-up visits for the pregnancy. Which statement by the client indicates that she understands the scheduling?

"From now until I am 28 weeks' pregnant, I will be coming once a month." Rationale: Continuous prenatal care is important for a successful pregnancy outcome. The recommended follow-up visit schedule for a healthy pregnant woman is as follows: every 4 weeks up to 28 weeks' (7 months') gestation; every 2 weeks from 29 to 36 weeks' gestation; every week from 37 weeks' gestation to birth.

A nurse is assessing a pregnant woman in her last trimester. Which question would be most appropriate to use to gather information about weight gain and fluid retention?

"How swollen do your ankles appear before you go to bed?" Rationale: Edema, especially in the dependent areas such as the legs and feet, occurs throughout the day due to gravity. It improves after a night's sleep. Therefore, questioning the client about ankle swelling would provide the most valuable information. Asking about her usual dietary intake would be valuable in assessing complaints of heartburn and indigestion. The size of maternity clothing may provide information about weight gain but would have little significance for fluid retention. Swelling in the face may suggest preeclampsia, especially if it is accompanied by dizziness, blurred vision, headaches, upper quadrant pain, or nausea.

The nurse is conducting a teaching session for breastfeeding mothers. Which statement by a mother requires further clarification by the nurse?

"I am glad I can have my two cups of coffee in the morning again." Explanation: Breastfeeding mothers should avoid caffeine because it delays iron absorption and passes through the milk and can slow infant weight gain. Similarly, spicy foods pass into the breastmilk and can affect the baby. Breastfeeding mothers need added calories and fluids.

The nurse is assessing a client's risk for sexually transmitted infections. Which statement by the client would be cause for concern?

"I am unsure who the father of the baby is. I will be raising it alone." Explanation: While many individuals have complex social issues, if a client states that she is unsure of the father of the baby, it is understood that she has had recent, multiple sex partners. Sex with multiple partners places the client and fetus at risk for a sexually transmitted infection. Not wanting to keep the baby, needing Rho(D) immune globulin, and having social issues does not place the client at risk for sexually transmitted infections.

A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching?

"I should substitute intercourse with nonsexual touch to avoid harming the fetus." Explanation: Sexual needs may be met through sexual intercourse with a partner as long as the pregnancy is healthy and there are no other risk factors, such as bleeding or rupture of membranes. Pregnancy is a time of a heightened need for touch, which may be met partially by sexual expression, but which can also be met through nonsexual touch, such as massage, caressing, or holding.

A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching?

"I wear knee-highs rather than pantyhose." Explanation: Women with varicosities should not wear knee-high stockings as they put pressure on leg veins and reduce venous return.

After teaching a pregnant woman how to perform fetal movement (kick) counts, the nurse determines that the teaching was successful when the client makes which statement?

"I'll sit comfortably in a recliner or lie on my side when I do the counts." Explanation: The client should perform the fetal movement (kick) counts in a relaxed environment and a comfortable position, such as a semi-Fowler or side-lying position. The woman needs to do fetal movement (kick) counts consistently, at approximately the same time each day. A woman should report a count of less than three fetal movements in an hour. A relaxed environment, a comfortable position, and consistency in performing the counts are important to identify changes.

After teaching the pregnant woman about ways to minimize flatulence and bloating during pregnancy, the nurse understands that which client statement indicates the need for additional teaching?

"I'll switch to chewing gum instead of using mints." Explanation: Eating mints can help reduce flatulence; chewing gum increases the amount of air that is swallowed, increasing gas build-up. Increasing fluid intake helps to reduce flatus. Gas-forming foods such as beans, cabbage, and onions should be avoided. Increasing physical exercise, such as walking, aids in reducing flatus.

The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus?

"The gloves they provide irritate my hands, so I don't use them." Explanation: There are various chemicals which are recognized for their teratogenic effects and must be avoided during pregnancy. The nurse should find out which chemicals the client is exposed to and determine the risk factor. The greatest danger is the client handling chemicals without a barrier protection such as gloves. The other issues may also be dangers depending on the chemicals and the environment in which the client is working and should also be evaluated.

A gravida woman in her second trimester has shared that she still enjoys a glass of wine about once a week with dinner. What response by the nurse is most appropriate?

"There is no amount of alcohol consumption in pregnancy that is considered safe for the fetus." Explanation: Alcohol ingestion during the pregnancy is considered unsafe at all points in the pregnancy. Alcohol can impact the fetus during each of trimester of pregnancy. There are no exact amounts of alcohol that can be ingested safely. Alcohol impacts each pregnancy and fetus differently. The best course of action is to share the dangers with the woman.

At 24 weeks' gestation a client is asked to drink a sweet orange solution and then wait an hour to have blood drawn. The client asks if this is the test to determine if she has diabetes. What is the best response by the nurse?

"This is a screening procedure. If your result is elevated you will be scheduled for a longer test to determine if you have gestational diabetes." Explanation: A glucose tolerance test involves a glucose load and a blood glucose level 1 hour later. It is a screening test used to determine if the client needs a full 3-hour oral glucose tolerance test. A 1-hour glucose tolerance test is not diagnostic of insulin resistance nor gestational diabetes. If the screening test is elevated the client is scheduled for the diagnostic test at approximately 24 to 26 weeks' gestation. If a client is eventually diagnosed with gestational diabetes, the initial treatment is diet therapy, not insulin.

A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?

"Try elevating your legs when you sit." Rationale: The client is experiencing dependent edema due to the effect of gravity and increased capillary permeability caused by elevated hormone levels and increased blood volume and accompanied by sodium and water retention. The best suggestion would be to encourage the woman to elevate her legs when sitting to promote venous return and minimize the effects of gravity. Neither fluids nor salt should be limited or eliminated. Six to eight glasses of water each day are necessary to replace fluids lost through perspiration. Foods high in sodium should be avoided. Spandex-type full-length pants would be constricting and interfere with venous return.

A pregnant woman in her second trimester tells the nurse, "I've been passing a lot of gas and feel bloated." Which suggestion would be helpful for the woman? Select all that apply.

"Watch how much beans and onions you eat." "Try exercising a little more." "Some say that eating mints can help." "Cut down on your intake of cheeses." Rationale: For gas and bloating, the nurse would instruct the woman to avoid gas-forming foods, such as beans, cabbage, and onions, as well as foods that have a high content of white sugar. Adding more fiber to the diet, increasing fluid intake, and increasing physical exercise are also helpful in reducing flatus. In addition, reducing the amount of swallowed air when chewing gum or smoking will reduce gas build-up. Reducing the intake of carbonated beverages and cheese and eating mints can also help reduce flatulence during pregnancy.

When providing preconception care to a client, which instruction will the nurse to provide about medications during pregnancy?

"You need to talk with your health care provider about using all prescription, over-the-counter, and herbal medications." Explanation: Medication use is common during pregnancy, with prevalence estimates generally exceeding 65% and increasing over the years. Pregnant women use a wide variety of both prescription and over-the-counter medications for both pregnancy-related conditions and conditions unrelated to pregnancy conditions. Little is known about the effects of taking most medications during pregnancy. It is best for pregnant women to not take any medications during their pregnancy. At the very least, they should be encouraged to discuss with the health care provider their current medications and any herbal remedies they take so that they can learn about any potential risks should they continue to take them during pregnancy. A common concern of many pregnant women involves the use of over-the-counter medications and herbal agents. Many women consider these products benign simply because they are available without a prescription. Although herbal medications are commonly thought of as "natural" alternatives to other medicines, they can be just as potent as some prescription medications. The nurse should encourage pregnant women to check with their health care providers before taking anything.

The nurse is preparing a client for a chorionic villi sampling procedure. Which factor should the nurse point out in the teaching session to the client?

"You'll have an ultrasound first and then the test." Rationale: With CVS, an ultrasound is done to confirm gestational age and viability. Then, under continuous ultrasound guidance, CVS is performed using either a transcervical or transabdominal approach. With the transcervical approach, the woman is placed in the lithotomy position and a sterile catheter is introduced through the cervix and inserted in the placenta, where a sample of chorionic villi is aspirated. This approach requires the client to have a full bladder to push the uterus and placenta into a position that is more accessible to the catheter. A full bladder also helps in better visualization of the helps in better visualization of the structures. With the transabdominal approach, an 18-gauge spinal needle is inserted through the abdominal wall into the placental tissue and a sample of chorionic villi is aspirated. Regardless of the approach used, the sample is sent to the cytogenetics laboratory for analysis. The results are usually available in less than one week. After the procedure, the woman is assisted into a position of comfort and any excess lubricant or secretions are cleaned from the area. The woman is instructed about signs to watch for and report, such as fever, cramping, and vaginal bleeding. The woman is also urged not to engage in any strenuous activity for the next 48 hours. RhoGAM is given to an unsensitized Rh-negative woman after the procedure. CVS can be used to detect numerous genetic disorders but not neural tube defects as no amniotic fluid is collected with this procedure. The woman would need to have MSAFP levels drawn at 16 to 18 weeks' gestation to test for neural tube defects.

A pregnant woman has a rubella titer drawn on her first prenatal visit. The nurse explains that this test measures:

immunity to German measles. Rationale: A rubella titer detects antibodies for the virus that causes German measles. If the titer is 1:8 or less, the woman is not immune and requires immunization after birth. Platelet level and red blood cell count would be determined by a complete blood count. Rh status would be determined by blood typing

The diagonal conjugate of a pregnant woman's pelvis is measured. Which measurement would the nurse interpret as presenting a potential problem?

12.0 cm Explanation: The diagonal conjugate, usually 12.5 cm or greater, indicates the anteroposterior diameter of the pelvic inlet. The diagonal conjugate is the most useful measurement for estimating pelvic size because a misfit with the fetal head occurs if it is too small.

The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age?

20 weeks Explanation: Some clients will not seek early prenatal care, especially if it is not their first pregnancy. The uterus expands to reach the height of the umbilicus by week 20. Before week 20 it is too low to be palpated, and after week 20 it may be beyond the umbilicus.

A nurse measures a pregnant woman's fundal height and finds it to be 28 cm. The nurse interprets this to indicate that the client is at how many weeks' gestation?

28 weeks' gestation Rationale: Typically, the height of the fundus is measured when the uterus arises out of the pelvis to evaluate fetal growth. At 12 weeks' gestation the fundus can be palpated at the symphysis pubis. At 16 weeks' gestation the fundus is midway between the symphysis and the umbilicus. At 20 weeks the fundus can be palpated at the umbilicus and measures approximately 20 cm from the symphysis pubis. By 36 weeks the fundus is just below the xiphoid process and measures approximately 36 cm.

A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at 39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation. Using the GTPAL method, the nurse would document her obstetric history as:

4 1 1 1 3. Rationale: Using the GTPAL method, the woman's history would be documented as 4 (her fourth pregnancy), 1 (number of term pregnancies), 1 (number of pregnancies ending in preterm birth), 1 (number of pregnancies ending before 20 weeks or viability), and 3 (number of living children).

A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every:

4 weeks. Explanation: The recommended follow-up visit schedule is every 4 weeks up to 28 weeks, every 2 weeks from 29 to 36 weeks, and then every week from 37 weeks to birth.

Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks gestation.

4, 1, 1, 1, 1 Explanation: The GTPAL system is used to classifying pregnancy status. G = gravida, T= term, P = preterm, A = number of abortions, L= number of living children.

A biophysical profile has been completed on a pregnant woman. The nurse interprets which score as normal?

9 Rationale: The biophysical profile is a scored test with five components, each worth 2 points if present. A total score of 10 is possible if the NST is used. Overall, a score of 8 to 10 is considered normal if the amniotic fluid volume is adequate. A score of 6 or below is suspicious, possibly indicating a compromised fetus; further investigation of fetal well-being is needed.

A client in the third trimester of pregnancy has to travel a long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client?

Always wear a three-point seat belt. Explanation: To promote easy and safe travel for the client, the nurse should instruct the client to always wear a three-point seat belt to prevent ejection or serious injury from collision. The nurse should instruct the client to deactivate the air bag if possible. The nurse should instruct the client to apply a nonpadded shoulder strap properly, ensuring that it crosses between the breasts and over the upper abdomen, above the uterus. The nurse should instruct the client to use a lap belt that crosses over the pelvis below—not over—the uterus.

What is the most effective way for a nurse to assess a woman's usual food intake during her pregnancy?

Ask her to describe her intake for the last 24 hours. Explanation: A 24-hour food intake history is the best method to assess food intake in all individuals.

At 32 weeks' gestation a client with a BMI of 23 has gained 24 lb (11 kg). What is the nurse's recommendation for weight gain for the remainder of this pregnancy?

Continue to gain approximately 1 lb (.45 kg) per week during this pregnancy. Explanation: Expected weight gain is 1.5 lb (0.68 kg) per month in the first trimester and 1 lb (.45 kg) per week for the second and third trimester. This client needs to continue to gain 1 lb (.45 kg) per week. Restricting weight gain near the end of pregnancy can negatively impact fetal growth.

Why is the first prenatal visit usually the longest prenatal visit?

Baseline data is collected. Explanation: The first prenatal visit is usually the longest because the baseline data to which all subsequent assessments are compared are obtained at this visit.

On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. The nurse documents this finding as:

Chadwick sign. Rationale: Chadwick sign refers to the bluish coloration of the cervix and vaginal mucosa. Hegar sign refers to softening of the isthmus. Goodell sign refers to softening of the cervix. Homans sign indicates pain on dorsiflexion of the foot.

A pregnant client wishes to know if sexual intercourse would be safe during her pregnancy. Which should the nurse confirm before educating the client regarding sexual behavior during pregnancy?

Client does not have cervical insufficiency. Explanation: The nurse should inform the client that sexual activity is permissible during pregnancy unless there is a history of cervical insufficiency, vaginal bleeding, placenta previa, risk of preterm labor, multiple gestation, premature rupture of membranes, or presence of any infection. Anemia and facial and hand edema would be contraindications to exercising but not intercourse. Freedom from anxieties and worries contributes to adequate sleep promotion.

A pregnant client at full-term gestation calls the nurse to report contractions every 6 to 7 minutes that are getting stronger. The membranes are intact. The client lives 45 minutes away from the hospital and had a 4-hour labor with the previous birth. What will the nurse advise?

Come to the hospital now for assessment. Explanation: Generally, clients are advised to come to the hospital once contractions are 5 minutes apart, but because this client has a history of fast (4 hour) labor and lives 45 minutes away from the hospital, the client should be advised to come to the hospital now. Membranes may rupture at any point in labor and should not dictate the timing of hospital admission. Bloody show is a normal finding in labor, but it does not determine the stage of labor or when the client should come to the hospital.

The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?

Continue this as long as she enjoys it. Explanation: Walking is an excellent exercise during pregnancy because it is low impact and increases venous circulation. Exercise should be maintained as long as it is comfortable, but intensity should not increase over what is normally performed.

A woman in her 20s explains to the nurse that she would like to eat more healthy foods during her pregnancy but is concerned about the high cost of food. She confides that she just makes minimum wage at her job and that things are tight for her financially. What would be the most appropriate intervention for the nurse to make?

Discuss the WIC program with the client. Explanation: WIC is a federal program that provides nutritional support for low-income women and children not only to reduce the risk of low birth weight but also to aide with the cost of newborn nutrition. Recommending that the client only purchase and eat fruits and vegetables would not be appropriate, as this would not provide needed protein, iron, and other nutrients. Offering to give money to the client would not be professionally appropriate. Because the client is no longer in school, she would not be eligible for the school lunch program.

A woman who is 4 months pregnant has pyrosis. Which suggestion would the nurse give her?

Eat small meals and do not lie down after meals. Explanation: Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the stomach causes regurgitation into the esophagus. Eating small meals and remaining upright limits the possibility of regurgitation.

When preparing a woman for an amniocentesis, the nurse would instruct her to perform which action?

Empty the bladder. Rationale: Before an amniocentesis, the woman should empty her bladder to reduce the risk of bladder puncture during the procedure. Showering with an antiseptic scrub and preprocedural sedation are not necessary. The woman usually is positioned in a way that provides an adequate pocket of amniotic fluid on ultrasound.

Click to highlight the findings that will require follow-up... A nurse is caring for a 20-year-old primigravida client who is at 18 weeks' gestation. The client had been experiencing occasional nausea and vomiting in the morning and now reports persistent nausea and vomiting in the past 48 hours. Client has lost 3 lb (1.36 kg) in 2 days. The nurse performs a comprehensive assessment on the client. Vital signs: heart rate, 110 beats/min, blood pressure 88/56 mm Hg. Laboratory values: blood urea nitrogen (BUN), 25 mg/dl (8.93 mmol/l) and sodium 148 mEq/l (148 mmol/l).

Explanation: Hyperemesis gravidarum usually occurs during the first trimester of pregnancy due to high human chorionic gonadotropin (hCG) levels. Hyperemesis gravidarum is persistent nausea and vomiting with weight loss due to inability to ingest food or fluid, which leads to dehydration. A 3-lb (1.36-kg) weight loss in 2 days due to persistent nausea and vomiting is an indication the client is experiencing hyperemesis gravidarum. The weight loss is due to the client's inability to ingest food or fluids, which leads to severe dehydration and malnutrition. The nurse should request intravenous fluids. A blood urea nitrogen (BUN) level of 25 mg/dl (8.9 mmol/l) (normal: 8 to 20 mg/dl; 2.9 to 7.5 mmol/l) is an indication that the client is dehydrated.A serum sodium level of 148 mEq/l (148 mmol/l) (normal: 135 to 145 mEq/l; 135 to 145 mmol/l) is an indication that the client is dehydrated. A blood pressure of 88/56 mm Hg may be an indication of dehydration. A heart rate of 110 beats/min is a compensatory mechanism due to the low blood pressure.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of spontaneous abortion (miscarriage) within the first trimester. The nurse is correct to document the history as:

G = 3, T = 1, P = 0, A = 1, L = 1 Explanation: The GTPAL stands for Gravida -- number of pregnancies, which is 3 (current, 4-year-old, and miscarriage); Term -- only one pregnancy thus far carried to term; Preterm deliveries -- 0; Abortions (either elective or miscarriage) -- 1; Living children -- 1. Do not be distracted by the twins. That is still one pregnancy.

During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. Which nursing diagnosis would be the priority for this client?

Impaired gas exchange related to pulmonary congestion Rationale: Typically, heart rate increases by approximately 10 to 15 beats per minute during pregnancy and the lungs should be clear. Dyspnea may occur during the third trimester as the enlarging uterus presses on the diaphragm. However, the findings described indicate that the woman is experiencing impaired gas exchange. There is no evidence to support supine hypotensive syndrome, increased metabolism, or anxiety.

A client's last menstrual period was April 11. Using the Naegele rule, her estimated date of delivery (EDD) would be:

January 18. Rationale: To use the Naegele rule, subtract 3 months and then add 7 days to the first day of the client's LMP (April 11): April minus 3 months is January, plus 7 days is 18. Thus, her EDB would be January 18 of the next year.

A client who is uncertain when her LMP occurred is given an EDD of April 23 after the first ultrasound. Based on this information, the nurse determines the client's LMP was probably which day?

July 16 Explanation: According to Naegele rule, the last menstrual period was July 16th. Take the LMP and add 7 days and subtract 3 months; if finding the LMP from the EDD, subtract 7 days and add 3 months.

The nurse is reviewing an employer's guidelines to support pregnant employees. When reviewing the information, which guideline requires further follow-up and education by the nurse?

Promote overtime shifts to save money for parental leave. Explanation: Excessive overtime and working longer than 8-hour shifts are associated with an increase in preterm labor and other pregnancy complications; this is not recommended. Providing an area for rest supports the need for additional rest by pregnant employees. Support hose help to promote venous return and are useful for employees who spend a lot of time standing. Modifying duties during later pregnancy is important, as balance may be compromised and strenuous activity is not recommended.

When describing perinatal education to a pregnant woman and her partner, the nurse emphasizes which goal as the primary one?

Provide knowledge and skills to actively participate in birth and parenting. Rationale: The primary focus of perinatal education is to provide information and support to clients and their families to foster a more active role in the upcoming birth. It also includes preparation for breastfeeding, infant care, transition to new parenting roles, relationships skills, family health promotion, and sexuality. Some methods of birth education focus on pain-free birth. Information provided in birth education classes helps to minimize anxiety and provide the couple with control over the situation, but elimination of anxiety or total control is unrealistic.

A nurse is caring for a client who is 8 months pregnant. Which instruction is the nurse most likely to give her?

Rest on the left side for at least 1 hour in the morning and afternoon. Explanation: During the last months of pregnancy, the nurse should instruct the woman to rest on her left side for at least 1 hour in the morning and afternoon. This position relieves fetal pressure on the renal veins, helps the kidneys excrete fluid, and increases flow of oxygenated blood to the fetus. The body's oil and sweat glands are more active than usual during pregnancy. Thus, a daily warm bath or shower is important, rather than a hot bath, which may produce hyperthermia. Nipple exercises and stimulation should not be done, especially in the third trimester, when they can cause uterine contractions and premature labor. Lanolin ointment may damage the areola and nipple. It has not been shown to be effective in preventing sore and cracked nipples. Lanolin is also a common allergen and may contain insecticide residuals such as DDT.

A client in her third trimester of pregnancy wishes to formula feed her baby. What instruction should the nurse provide?

Serve the formula at room temperature. Explanation: The nurse should instruct the client to serve the formula to her infant at room temperature. The nurse should instruct the client to follow the directions on the package when mixing the powder because different formulas may have different instructions. The infant should be fed every 3 to 4 hours, not every 8 hours. The nurse should specifically instruct the client to avoid refrigerating the formula for subsequent feedings. Any leftover formula should be discarded.

A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?

Stop and walk every 2 hours. Explanation: Walking increases venous return and reduces the possibility of thrombophlebitis, a risk for pregnant women who sit for extended periods of time. Limiting mileage, sitting in the back with the feet elevated, and limiting trips may help, but they are not enough to prevent phlebitis.

The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage?

Stretching and breathing exercises such as yoga Explanation: It is important to exercise during pregnancy. One excellent type of exercise includes yoga, which reduces stress and increases relaxation. Yoga also gently stretches muscles and can increase muscle tone. Contact and high-impact sports are not appropriate for the pregnant mother. Hot areas such as a jacuzzi, hot tub, and sauna are also inappropriate.

The health care provider has prescribed an over-the-counter antacid for a pregnant client in her first trimester who is having ongoing nausea, vomiting, and heartburn. Which instruction concerning the antacid should the nurse prioritize after noting the client is also prescribed a multivitamin supplement?

Take antacid 1 hour after the multivitamin. Explanation: Antacids interfere with the uptake of the vitamin contents so the client should take the antacid 1 hour after taking the multivitamin. Caffeine should be avoided due to increases in blood pressure and diuretic effects. Antacids can be taken more often than solely at bedtime, and some clients need them after each meal. Antacids do not have to be taken with dairy products. The priority is to avoid allowing the antacid to cancel out the multivitamin.

The nurse is assisting a pregnant client who underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?

The fetal heart rate increases with activity and indicates fetal well-being. Explanation: A nonstress test is a noninvasive way to monitor fetal well-being. A reactive NST is a positive sign the fetus is tolerating pregnancy well by demonstrating heart rate increase with activity, and this indicates fetal well-being. This test is not used to determine congenital anomalies or deformities. It does not determine the speed by which fetus is developing. Further evaluation would be necessary if the results were nonreactive.

The nurse is assessing a 24-year-old pregnant client who reports excessive vaginal discharge that is messy and unpleasant but without a strong odor, itching, or irritation present. Which response should the nurse prioritize?

Use sanitary pads. Explanation: Vaginal discharge increases during pregnancy and is a concern for many women. Encourage the client to keep clean and wear sanitary pads as needed. Douching may be dangerous for the mother. STIs are not indicated simply by discharge. Pregnant women should not decrease fluid intake.

Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth. The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

between 24 and 28 weeks' gestation Explanation: Screening for gestational diabetes is best done between 24 and 28 weeks' gestation, unless screening is warranted in the first trimester for high-risk reasons. If the initial screening is elevated, then further testing should be conducted to confirm the diagnosis.

A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function?

amniotic fluid volume Explanation: A biophysical profile combines five parameters (fetal reactivity, fetal breathing movements, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment. The fetal heart and breathing record measures short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.

A nurse at the health care facility assesses a client at 20 weeks' gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?

at the level of the umbilicus Explanation: In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 to 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy, the fundus should reach the xiphoid process.

A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location?

at the umbilicus Explanation: At 20 weeks, the fundus can be palpated at the umbilicus. A fundus of 12 weeks' gestation is palpated at the symphysis pubis. At 16 weeks' gestation, the fundus is midway between the symphysis pubis and umbilicus. At 36 weeks' gestation, the fundus can be palpated just below the ensiform cartilage.

A young couple are concerned that their fetus may be born with sickle cell anemia. The nurse explains that the recessive traits of sickle-cell anemia can be determined by using which test?

chorionic villus sampling Explanation: Chorionic villus sampling (CVS) is a procedure for obtaining a sample of the chorionic villi for prenatal evaluation of chromosomal disorders, enzyme deficiencies, fetal gender determination, and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay-Sachs disease. Amniocentesis is used to evaluate for neural tube defects, chromosomal disorders, and inborn errors of metabolism. Blood typing is performed via a blood sample. Percutaneous umbilical blood sampling allows for rapid chromosomal analysis.

The nurse is teaching about an iron supplement that the client is going to take every day. The nurse teaches the client to take the iron supplement with which type of fluid?

citrus juice Explanation: The citric acid in juice enhances absorption of iron in the GI tract. Ice water and tea do not enhance iron absorption, and milk can inhibit iron absorption.

A nurse is reviewing the results of four clients who have undergone amniocentesis. Which client would the nurse recommend that the health care provider see first?

client at 38 weeks' gestation with fetal heart rate of 110 and green amniotic fluid sample Rationale: The client at 38 weeks' gestation should be evaluated first because the green amniotic fluid suggests possible meconium staining and the fetal heart rate is bradycardic. Immediate evaluation and intervention would be essential. A high alpha fetoprotein level may suggest a neural tube defect or possible chromosomal abnormality. Although important to address, this client would not be the priority. The client at 34 weeks' with gestational diabetes and an L/S ratio of 2:1 indicates that the lung of the fetus are mature, should delivery be necessary. Amniotic fluid that is negative for bilirubin is a normal finding.

While assessing a client's breast during the third trimester, which finding would the nurse expect?

colostrum from the nipples Explanation: During the third trimester, the nipples express colostrum. Areolae and nipples appear enlarged with darker pigmentation during the third trimester. The nurse assesses for the softness of the breast, color, and pain in the nipple area in nursing mothers.

A 24-year-old client who is planning to become pregnant comes to the clinic for an evaluation. When assessing the client, which finding would alert the nurse to implement measures to reduce the client's risk for problems during pregnancy? Select all that apply.

drinks wine 3 to 4 times/week uses ibuprofen daily Rationale: The use of alcohol and prescription and over-the-counter drugs can be harmful to a growing fetus. Thus the nurse would need to address these areas with the client. If the client was still smoking, then that too would need to be addressed. Healthy nutrition is important, but being a vegetarian does not necessarily indicate that the client is a nutritional risk. A BMI of 22 is considered normal and would not pose a problem.

When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?

fundal height measurement Rationale: On every follow-up visit, fundal height measurements are performed to evaluate fetal growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be done on the initial visit and then repeated if the woman's status indicates a need for doing so. Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal period, but it is not done at every visit.

During a routine prenatal visit, a client at 36 weeks' gestation states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. The nurse would develop a plan of care identifying interventions to promote which area as the priority?

gas exchange Rationale: Typically, heart rate increases by approximately 10 to 15 beats per minute during pregnancy and the lungs should be clear. Dyspnea may occur during the third trimester as the enlarging uterus presses on the diaphragm. However, the findings described indicate that the woman is experiencing impaired gas exchange. There is no evidence to support problems with tissue perfusion, activity, or anxiety.

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider. Which signs and symptoms would the nurse include? Select all that apply.

headache with visual changes in the third trimester sudden leakage of fluid during the second trimester lower abdominal pain with shoulder pain in the first trimester Explanation: Danger signs and symptoms that need to be reported immediately include headache with visual changes in the third trimester; sudden leakage of fluid in the second trimester; and lower abdominal pain accompanied by shoulder pain in the first trimester. Urinary frequency in the third trimester, nausea and vomiting during the first trimester, and backache during the second trimester are common discomforts of pregnancy.

A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband." The woman's pregnancy has been uneventful. The nurse responds based on the understanding that:

it is safe to have intercourse at this time. Rationale: Sexual activity is permissible during pregnancy unless there is a history of vaginal bleeding, placenta previa, risk of preterm labor, multiple gestation, incompetent cervix, premature rupture of membranes, or presence of infection. Rupture of membranes or premature labor is unlikely since the woman's pregnancy has been uneventful so far. Alternative sexual positions may be necessary as the woman's abdomen increases in size.

The nurse is assessing the latest laboratory results of a pregnant client who is at 17 weeks gestation. The nurse should prepare to teach the client about which possible defects after noting the maternal serum alpha-fetoprotein level is elevated above normal?

open spinal defects Rationale: Elevated MSAFP levels are associated with open neural tube defects, underestimation of gestational age, the presence of multiple fetuses, gastrointestinal defects, low birth weight, oligohydramnios, material age, diabetes, and decreased maternal weight. Lower-than-expected MSAFP levels are seen when fetal gestational age is overestimated or in cases of fetal death, hydatidiform mole, increased maternal weight, maternal type 1 diabetes, and fetal trisomy 21 (Down syndrome) or 18. Fetal hypoxia would be noted with fetal heart rate tracings and via nonstress and contraction stress testing. Maternal hypertension would be noted via serial blood pressure monitoring.

After teaching a group of prospective new parents about the different perinatal education methods, the nurse determines that the teaching was successful when the parents identify which method as the Bradley method?

partner-coached method Rationale: The Bradley method is also a partner-coached method that uses various exercises and slow, controlled abdominal breathing to accomplish relaxation and active participation of the partner as labor coach. The Lamaze method is a psychoprophylactic or mind prevention method. The Dick-Read method is referred to as natural birth. Dick-Read believed that prenatal instruction was essential for pain relief and that emotional factors during labor interfered with the normal labor progression. The woman achieves relaxation and reduces pain by arming herself with the knowledge of normal childbirth and using abdominal breathing during contractions.

A nurse is reviewing the medical record of a pregnant woman and notes that she is gravida II. The nurse interprets this to indicate the number of:

pregnancies. Rationale: Gravida refers to a pregnant woman—gravida I (primigravida) during the first pregnancy, gravida II (secundigravida) during the second pregnancy, and so on. Para refers to the number of births at 20 weeks or greater that a woman has, regardless of whether the newborn is born alive or dead. "A" would be used to denote the number of abortions and "P" would be used to denote the number of preterm births when using the GTPAL system.

During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. This occurs about 4 or 5 times during the testing period. The nurse interprets this as:

reactive pattern. Rationale: A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm.

The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?

rubella Explanation: Most vaccines are contraindicated during pregnancy and are considered teratogenic, such as rubella. Penicillin and acetaminophen may be taken under provider supervision. Folic acid supplementation should be encouraged.

The nurse educates the vegetarian client about which nutritional need during pregnancy?

taking a B12 supplement Explanation: B12 is found almost exclusively in animal proteins and therefore is absent in the vegetarian diet. Fiber and dark green vegetables are needed. Vitamins A and C are not protein based and are found in a vegetarian diet.

The nurse is assisting a primigravida on calculating the due date of her baby using Naegele rule. The most important information provided by the mother is:

the first day of the last menstrual period. Explanation: Naegele rule is calculated using the first day of the last menstrual period. From there, 7 days are added and then 3 months are subtracted. The ovulation date, intercourse date, or last day of the menstrual period are not needed.

A client comes to the prenatal clinic for her first visit. When determining the client's estimated due date, the nurse understands what which method is the most accurate?

ultrasound Rationale: Although there are several methods for determining the EDD, the ultrasound is considered the most accurate method for dating the pregnancy.

A pregnant woman is scheduled to undergo an amniocentesis. When explaining this test to the client, the nurse would also include information about which test being done at the same time?

ultrasound Rationale: An ultrasound is used to confirm placental location during amniocentesis. Chorionic villus sample, biophysical profile, and Doppler flow study are not done at the same time as an amniocentesis.

A nurse is teaching a pregnant client in her first trimester about discomforts that she may experience. The nurse determines that the teaching was successful when the woman identifies which discomforts as common during the first trimester? Select all that apply.

urinary frequency breast tenderness cravings Rationale: Discomforts common in the first trimester include urinary frequency, breast tenderness, and cravings. Backache and leg cramps are common during the second trimester. Legs cramps are also common during the third trimester.

A nurse is describing the various birth methods to pregnant couples. Which information would the nurse include as part of the Lamaze method?

use of specific breathing and relaxation techniques Rationale: Lamaze is a psychoprophylactic ("mind prevention") method of preparing for labor and birth that promotes the use of specific breathing and relaxation techniques. The Bradley method emphasizes the pleasurable sensations of birth, teaching women to concentrate on these sensations while "turning on" to their own bodies. The Dick-Read method seeks to interrupt the circular pattern of fear, tension, and pain during the labor and birthing process.

A pregnant woman is scheduled for chorionic villus sampling. The nurse is describing the procedure and the potential for complications. When providing care to the client after the testing, the nurse would be alert for which complication as the most common? Select all that apply.

vaginal bleeding cramping Rationale: Although spontaneous abortion, rupture of membranes, and hematoma can occur after chorionic villus sampling, vaginal bleeding and cramping are the most common.