Pregnancy, Labor, Childbirth, Postpartum - At Risk

When entering the room of a client in active labor to answer the call light, the nurse sees that she is ashen gray, dyspneic, and clutching her chest. What should the nurse do after pressing the emergency light in the client's room?

Administer oxygen by facemask.

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may:

Allow the clients to express their grief

A nurse in the prenatal clinic is assessing a woman at 34 weeks' gestation. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action?

Arranging transportation to the hospital

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?

Calcium gluconate

A client with worsening preeclampsia is admitted to the high-risk unit, and the nurse manager places her in a private room. A nonstimulating environment is important for a client with increased cerebral irritability because it:

Decreases the probability of generalized seizures

What is the initial responsibility of a nurse teaching the pregnant adolescent?

Encouraging her to continue regularly scheduled prenatal care

A client who is 21 weeks pregnant loses the baby because of an incompetent cervix. Once the client's physical needs have been assessed and met, what is the best way for the nurse to meet the client's psychological needs?

Encouraging the client to see and hold the baby while still possible

During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed?

Family history of genetic abnormalities

What should be included in the nursing care for a client at 41 weeks' gestation who is to have a contraction stress test?

Having the client empty her bladder

Several hours after delivery, a new mother expresses ambivalence about her infant. How will the nurse promote bonding between this mother and her newborn?

Having the mother feed the infant

A client in the 38th week of gestation exhibits a slight increase in blood pressure. The health care provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position?

It increases blood flow to the fetus.

A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. What does the nurse suspect precipitated this preterm labor?

Incompetent cervix

A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse do first?

Insert an intravenous catheter

A client at term is admitted in active labor. She has tested positive for HIV. Which intervention in the standard orders should the nurse question as a risk to the fetus?

Internal fetal scalp electrode

What signs and symptoms of withdrawal does the nurse identify in a postpartum client with a history of opioid abuse?

Irritability and muscle tremors

A pregnant client with a history of preterm labor is at home on bedrest. What instructions should a teaching plan for this client include?

Lie on the side with the head raised on a small pillow.

A client who had tocolytic therapy for preterm labor is being discharged. What instructions should the nurse include in the teaching plan?

Limit daily activities.

Which client should the nurse identify as being at greatest risk for a hypertensive disorder of pregnancy?

Obese primigravida

A client arrives at the hospital at 38 weeks' gestation with profuse painless bright-red vaginal bleeding. She states that it came on suddenly, without any contractions. Which condition does the nurse report to the health care provider?

Placenta previa

What is most important for the nurse to assess if a client has a precipitous birth?

Profuse bleeding

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at −2. For what complication should the nurse assess when caring for this client?

Prolapse of the umbilical cord

Which client is at risk for a postpartum infection?

A woman who required catheterization after voiding less than 75 mL

To prevent or stabilize a client in heroin withdrawal during labor, which medication should be administered as ordered if the woman is nauseated, vomiting, or did not receive her daily dose at a chemical dependence center?

Dolophine (Methadone)

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response?

Extra circulating glucose causes the fetus to acquire fatty deposits.

A nurse is concerned about a client's mother-infant bonding when on the first postpartum day she is reluctant to:

Look at her newborn's face.

While receiving betamimetic (tocolytic) therapy for preterm labor the client begins to experience muscle tremors and exhibit signs of nervousness. She reports, "My heart is racing." The nurse identifies that the client's pulse rate is 110 beats/min and regular. What should the nurse do next?

Reassure the client that these are expected side effects of the medication.

A client who has undergone a cesarean birth because of the presence of active genital herpes is transferred to the postpartum unit. What type of isolation precautions does the nurse plan to institute?

Contact

A client with type 1 diabetes is scheduled for an amniocentesis at 36 weeks' gestation. She asks the nurse why this is being done so late in her pregnancy. What should the nurse consider before responding?

Fetal lung maturity may be evaluated.

A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left occiput posterior position. The client's membranes rupture spontaneously. What observation requires the nurse to notify the practitioner?

Greenish amniotic fluid

A nurse is caring for a client who has had a spontaneous abortion. For what complication should the nurse assess this client?

Hemorrhage

What is the priority nursing care after an amniocentesis?

Monitoring for signs of uterine contractions

What is the priority nursing intervention on admission of a primigravida in labor?

Monitoring the fetal heart rate

A woman in labor arrives at the birthing unit. She tells the nurse, "They told me the last time I was at the clinic that I had Chlamydia, but I stopped taking the antibiotic after 3 days because I felt better." What potential neonatal disorder transmitted during birth most concerns the nurse because of the inadequate treatment?

Ophthalmia neonatorum

A primigravida in whom placenta previa has already been diagnosed is admitted with bright-red vaginal bleeding at 34 weeks' gestation. What is the nurse's initial intervention?

Positioning the client in the side-lying position to ease pressure on the cervix

A pregnant client with type 1 diabetes is visiting the prenatal clinic for the first time. What is the primary long-term goal for this client?

Pregnancy will end with the birth of a healthy infant.

A client is admitted with a diagnosis of preeclampsia. What significant clinical finding does the nurse expect when reviewing the client's history?

Proteinuria

An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. What is the nurse's most important goal for this client?

Reducing her blood pressure

A client had a cesarean birth 4 hours ago. What is the major nursing intervention at this time?

Relieving postoperative pain

A client being prepared for surgery because of a ruptured tubal pregnancy complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy?

Shock

A client with mild preeclampsia is being treated on an outpatient basis. Three days of bedrest is prescribed. What position should the nurse encourage the client to maintain while in bed?

Side-lying

Oxytocin (Pitocin) augmentation by way of intravenous piggyback is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply.

Stopping the infusion Turning the client on her side Notifying the health care provider Verifying the duration of contractions

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?

These accelerations are a sign of fetal well-being.

A nurse is assessing a pregnant client at the end of her second trimester. What clinical finding causes the nurse to suspect that the client has preeclampsia?

Two samples showing proteinuria

A client at 37 weeks' gestation is admitted to the birthing unit from the emergency department. She arrived in an ambulance after a motor vehicle accident. Her blood pressure is 90/60 mm Hg, pulse is 108 beats/min, and respiratory rate is 24 breaths/min. She is reporting sharp abdominal pain. What is the priority nursing intervention at this time?

Applying an electronic fetal monitor

A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and 60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood from the vagina. The uterus is irritable on palpation and does not relax fully between contractions. What is the initial nursing action?

Assessing the fetal heart rate, uterine activity, and blood pressure

A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How can the nurse evaluate whether the client's bladder is distended?

By palpating the client's suprapubic area gently

A nurse is caring for a postpartum client with a history of rheumatic heart disease. The nurse plans care for this client with the knowledge that the client should:

Be monitored during the first 48 hours because of the stress on the cardiopulmonary system

A nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action?

Changing the maternal position

A client at 35 weeks' gestation is admitted to the high-risk unit with a small amount of bright-red vaginal bleeding. Once the client has been placed in a bed, what is the next nursing intervention?

Checking fetal heart tones

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?

Partial abruptio placentae

A nurse is assessing a woman with a probable ruptured tubal pregnancy. What clinical manifestation requires immediate intervention?

Sudden onset of knifelike pain in one of the lower quadrants

A client with type 1 diabetes is being counseled on what to expect during her recently confirmed pregnancy. Which statement indicates that the client needs further education?

"I can expect that my insulin requirements will be less."

A teenager at 32 weeks' gestation is hospitalized with preeclampsia. She is anorexic and appears depressed. Which comment indicates to the nurse that further exploration of the client's emotional status is indicated?

"I was really happy before I got pregnant."

A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect her diet and insulin needs. How should the nurse respond?

"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."

After a difficult labor a client gives birth to a 9-lb boy who dies shortly afterward. That evening the client tearfully describes to the nurse her projected image of her son and what his future might have been. What is the nurse's most therapeutic response?

"It must be difficult to think of him now."

A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use?

Amount of blood lost in relation to usual menstrual flow

A nurse notifies the health care provider that a client has been admitted to the high-risk unit in her 36th week of gestation. She is bleeding, has severe abdominal pain and a rigid fundus, and is demonstrating signs of shock. For what intervention should the nurse prepare?

An immediate cesarean birth

Which nursing assessment is most important for a large-for-gestational-age (LGA) infant of a diabetic mother (IDM)?

Blood glucose level less than 40 mg/dL

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?

Cesarean birth

A nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained?

Checking the client's reflexes

Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identify that indicates the need for further instruction about complications associated with a multiple gestation?

Down syndrome

A client is admitted with a marginal placenta previa. What should the nurse have available?

Two units of typed and screened blood

A nurse is caring for a client who has been admitted with a tentative diagnosis of placenta previa. What procedure does the nurse anticipate?

Ultrasound examination

A pregnant client who has type 2 diabetes and a history of three miscarriages is scheduled for a contraction stress test. Before the test she begins to cry while answering the nurse's questions about her previous pregnancies. She states, "I know it's my diabetes. This baby will never live. It's all my fault." What is the best response by the nurse?

"This must be very stressful for you."