Unit 6
A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?
1. "Uterine contractions are stimulated by Leopold's maneuvers." 2. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." 3. "The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation." 4. "Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions." 3 Rationale: A contraction stress test assesses placental oxygenation and function and determines the fetus's ability to tolerate labor, as well as its well-being. The test is performed if the nonstress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40 seconds or more during a 10-minute period have occurred. Frequent maternal blood pressure readings are performed, and the client is monitored closely while increasing doses of oxytocin are given. Leopold's maneuvers are performed to locate the position of the fetus.
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Outline of fetus via radiography or ultrasound 6. Fetal heart rate detected by a nonelectronic device 1,2,3,4 Rationale: The probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.
The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.
1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Increased pulse rate 5. Increased respiratory rate 1,2 Rationale: Signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia.
During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?
1. "I can eat more sweets now because I need more calories." 2. "I need more fat in my diet so that the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." 4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation." 4 Rationale: An increase in calories is needed during pregnancy, but concentrated sugars should be avoided because they may cause hyperglycemia. Per health care provider recommendations, fat intake should be 20% to 30% of the total calories. In addition, the client with diabetes needs about 50% to 60% of her caloric intake from carbohydrates and about 12% to 20% from protein. High-fiber foods will control blood glucose levels and prevent constipation.
A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?
1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava 3 Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.
The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if which is observed?
1. Rapid clotting times 2. Pain and swelling of the calf of one leg 3. Laboratory values that indicate increased platelets 4. Petechiae, oozing from injection sites, and hematuria 4 Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.
