UWorld Maternity

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia 2. Fetal tachycardia with moderate variability 3. Increased anxiety and discomfort with contractions 4. Painful, strong contractions every 3-4 minutes

1 Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option 2) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. (Option 3) Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. (Option 4) The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. Educational objective: Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is most concerning and requires the nurse to follow up? 1. Fetal heart rate remains 206/min 2. Fetus kicked 4 times in the past hour 3. Mother reports feeling 2 contractions every hour 4. Mother's hemoglobin is 11 g/dL (110 g/L)

1 Fetal tachycardia is a baseline of >160 beats/min for >10 minutes. Tachycardia needs evaluation and continued surveillance. The most sensitive indicators of fetus health are fetal movement and fetal heart rate. (Option 2) This is an expected finding. Monitoring fetal movement/kick counts is a primary method of fetal surveillance. The reassuring finding is when the movement equals or exceeds the established baseline. In general, 4 movements/hour or 10 distinct fetal movements within 2 hours is a reassuring finding. (Option 3) Braxton-Hicks contractions are felt mid-pregnancy onward. These painless, occasional physiological contractions are normal. The contractions are a concern if they become regular and persist. (Option 4) During pregnancy, hemoglobin can drop to 11 g/dL (110 g/L), a condition known as physiological anemia of pregnancy. Due to the increased oxygen requirements of pregnancy, the red blood cell count increases 30%. However, anemia can result from an increase in the plasma volume that is relatively larger than the increase in red blood cells. This lowered maternal hemoglobin is within the expected range. Educational objective: Sustained fetal tachycardia (>160/min for >10 minutes) is a concerning finding that requires further follow-up

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client? 1. Administration of prophylactic antibiotics 2. Assessment of uterine contraction frequency 3. Collection of a clean-catch urine specimen 4. Vaginal examination to assess cervical dilation

1 Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive. If GBS status is unknown, antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks (Option 1). (Option 2) Part of the client's assessment includes evaluation of the uterine contraction pattern. However, the client and newborn are at risk for infection due to prolonged rupture of membranes and unknown GBS status, so antibiotic administration is the priority. (Option 3) A urine specimen is often collected to evaluate for proteinuria in clients with elevated blood pressure or to assess for urinary tract infection in symptomatic clients. Urine specimen collection is not the priority for this client. (Option 4) Vaginal examinations should be limited in the presence of ruptured membranes. Multiple vaginal examinations in such a client correlate with an increased risk for infection (eg, chorioamnionitis). Educational objective: Group B Streptococcus (GBS) infection can be transmitted to the newborn during labor and birth and cause serious complications. Indications for prophylactic antibiotics during labor include maternal GBS-positive status or unknown GBS status with fever ≥100.4 F (38 C), preterm gestation, and/or prolonged rupture of membranes.

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education? 1. "I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected." 2. "I will establish a second IV line with an 18-gauge catheter." 3. "I will initiate serial blood pressure monitoring every 3-5 minutes." 4. "I will notify anesthesia and operating room staff of the client's condition immediately."

1 Uterine inversion is a rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock. Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider (HCP) is the first step in resolving the inversion and requires a soft, uncontracted uterus. Tocolytics (eg, terbutaline) or inhaled anesthetics may be needed to assist with uterine relaxation. Uterotonic medications (eg, oxytocin, carboprost) must be delayed or discontinued until after the HCP has corrected the inversion (ie, manual uterine replacement) (Option 1). After uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding. (Option 2) Initiating a second, large-bore (eg, 18-gauge) IV line is an important intervention that allows for adequate volume resuscitation (eg, fluids, blood products) as needed for hemorrhage. (Option 3) Serial blood pressure monitoring (eg, every 3-5 min) helps the nurse assess for worsening hypovolemic shock. (Option 4) If manual uterine replacement through the vagina is unsuccessful, emergency laparotomy (ie, replacement via abdominal incision) may be necessary; it is appropriate to notify surgical staff members who will be involved. Educational objective: Uterine inversion is a postbirth complication in which the uterine fundus collapses into the uterine cavity, resulting in sudden hemorrhage and hypovolemic shock. Initially, a soft, uncontracted uterus is needed to correct the inversion (ie, manual uterine replacement), and uterotonic administration (eg, oxytocin) is delayed until after the uterus is replaced.

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 3. Assisting with artificial rupture of membranes 4. Initiating IV magnesium sulfate 5. Obtaining fetal heart tones once per shift

1, 2, 4 Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: - Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option 1) - Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option 2) - Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option 4) - Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect - Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained (Option 3) Artificial rupture of membranes (AROM), or amniotomy, is performed to augment labor or assess amniotic fluid in clients who are at term gestation. For clients in PTL, the goal is to prolong pregnancy if possible. Therefore, AROM is contraindicated. (Option 5) Clients with suspected PTL should be placed on continuous fetal monitoring to assess for increasing frequency and duration of contractions and to evaluate fetal tolerance of labor. Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion. Educational objective: Preterm labor is progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate several interventions, including administration of IM antenatal glucocorticoids, antibiotics, and IV magnesium sulfate.

A nurse is evaluating the fetal monitoring strip of a laboring primigravida at 38 weeks gestation who is receiving an oxytocin infusion and has external fetal monitors and an intrauterine pressure catheter in place. Which of the following interventions should the nurse implement? Click on the exhibit button for additional information. Select all that apply. 1. Administer supplemental oxygen by mask 2. Initiate an IV bolus of 0.9% saline 3. Prepare for amnioinfusion 4. Reposition the client to supine 5. Stop the oxytocin infusion

1, 2, 5 Late decelerations occur after the onset of a uterine contraction and continue beyond its end. The lowest point (nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline. Late decelerations occur when fetal oxygenation is compromised (eg, uteroplacental insufficiency, uterine tachysystole, hypotension). Immediate steps to correct late decelerations include: - Stopping oxytocin if it is being administered (Option 5) - Repositioning the client to the left/right side - Administering oxygen by face mask (Option 1) - Administering an IV bolus of isotonic fluid (eg, lactated Ringer solution, 0.9% saline) as needed (Option 2) If late decelerations persist or variability is absent or minimal, the nurse should prepare for emergency delivery. (Option 3) Amnioinfusion is administered through an intrauterine pressure catheter to relieve variable decelerations, not late decelerations; variable decelerations are usually caused by cord compression secondary to loss of amniotic fluid (eg, after rupture of membranes, because of oligohydramnios). (Option 4) Supine positioning can obstruct blood flow to the placenta. The client should be placed in a side-lying position to promote placental perfusion. This action relieves compression of the aorta and inferior vena cava, which can affect cardiac output, cause hypotension, and decrease placental perfusion. Educational objective: Late decelerations occur when oxygenation to the fetus is compromised and require immediate intervention. The nurse caring for a client with late decelerations should stop oxytocin, place the client in a side-lying position, apply oxygen by face mask, and administer an IV fluid bolus as needed.

A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? Select all that apply. 1. Additional ultrasound around 36 weeks gestation 2. Clearance for sexual activity if bleeding stops 3. Discharge home if bleeding stops and fetal status is reassuring 4. Scheduled cesarean birth before onset of labor 5. Weekly vaginal examinations to assess for cervical change

1, 3, 4 In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs. As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option 1). (Options 2 and 5) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended. Educational objective: Clients with placenta previa are at risk for hemorrhage. Vaginal examinations are contraindicated, and pelvic rest is recommended to prevent disruption of placental vessels. A cesarean birth is planned prior to onset of labor.

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply. 1. Influenza injection 2. Influenza nasal spray 3. Measles, mumps, and rubella 4. Tetanus, diphtheria, and pertussis 5. Varicella

1, 4 Health promotion during pregnancy includes the administration or avoidance of certain vaccines to decrease risks to mother and fetus. Pregnant women have suppressed immune systems and are at increased risk for illness and subsequent complications. Some viruses (eg, rubella, varicella) can cause severe birth defects if contracted during pregnancy. Inactivated vaccines contain a "killed" version of the virus and pose no risk of causing illness from the vaccine. Some vaccines contain weakened (ie, attenuated) live virus and pose a slight theoretical risk of contracting the illness from the vaccine. For this reason, women should not receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving such a vaccine. The tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for all pregnant women between the beginning of the 27th and the end of the 36th week of gestation as it provides the newborn with passive immunity against pertussis (whooping cough) (Option 4). During influenza season (October-March), it is safe and recommended for pregnant women to receive the injectable inactivated influenza vaccine regardless of trimester (Option 1). (Options 2, 3, and 5) The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are contraindicated in pregnancy. Educational objective: Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect pregnant clients from illness and provide the fetus with passive immunity. Live virus vaccines are contraindicated in pregnancy.

A client at 35 weeks gestation is admitted to the labor and delivery unit for severe pre-eclampsia. She is started on IV magnesium sulfate for seizure prophylaxis. Which of the following signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply. 1. 0/4 patellar reflex 2. Blood pressure of 156/84 mm Hg 3. Client voiding 600 mL in 8 hours 4. Respirations of 10/min 5. Serum magnesium level of 8.0 mEq/L (4 mmol/L)

1, 4, 5 IV magnesium sulfate is administered for seizure (eclampsia) prophylaxis in pregnant clients with pre-eclampsia. A loading dose of 4-6 g of magnesium sulfate, followed by a maintenance dose of 1-2 g/hr, helps achieve therapeutic magnesium levels of 4-7 mEq/L (2.0-3.5 mmol/L). Magnesium toxicity may occur when magnesium levels are >7 mEq/L (3.5 mmol/L), which causes central nervous system depression and blocks neuromuscular transmission (Option 5). Absent or decreased deep tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs, scored on a scale of 0 to 4+, should be frequently assessed during magnesium sulfate infusion; normal findings are 2+ (Option 1). If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression (<12 breaths/min), followed by cardiac arrest (Option 4). Administration of calcium gluconate (antidote) is recommended in the event of cardiorespiratory compromise. (Option 2) Hypertension is a sign of pre-eclampsia, not of magnesium toxicity. Hydralazine (Apresoline) and/or labetalol are used to lower blood pressure if needed (ie, when >160/110 mm Hg). (Option 3) Urine output <30 mL/hr is a sign that magnesium toxicity may be likely, as magnesium is excreted through the urine. Educational objective: The therapeutic level of magnesium for pre-eclampsia/eclampsia treatment is 4-7 mEq/L (2.0-3.5 mmol/L). Signs of magnesium toxicity may be noted with serum levels >7 mEq/L (3.5 mmol/L) and include absent or decreased deep tendon reflexes, respiratory depression, and cardiac arrest. Calcium gluconate (antidote) should be readily available in the event of cardiorespiratory compromise.

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply. 1. Abnormal or indeterminate fetal heart rate patterns 2. Delayed breast milk production 3. Placenta previa 4. Postpartum hemorrhage 5. Uterine tachysystole

1, 4, 5 Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: - Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions (Option 1). - Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern - Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin (Option 4). - Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. - Uterine tachysystole (ie, >5 contractions in 10 minutes) (Option 5) (Option 2) Endogenous oxytocin is excreted by the pituitary gland and triggers the milk ejection/let-down reflex. Administration of exogenous oxytocin (ie, synthetic oxytocin) has no known effect on milk production. (Option 3) Uterine stimulation from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa (ie, abnormal implantation of the placenta over the cervical os) is unrelated to oxytocin administration. Educational objective: Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle and is used to induce or augment labor and to prevent postpartum hemorrhage (PPH). Oxytocin administration increases the risk of abnormal fetal heart rate patterns, emergency cesarean birth, uterine tachysystole, placental abruption, and uterine rupture. Prolonged administration increases the risk of water intoxication and PPH.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" 2. "Do you wipe from front to back after urinating?" 3. "Have you found that you urinate more frequently since becoming pregnant?" 4. "Have you had a urinary tract infection in the past?"

1. "Are you having any pain in your lower back or flank area?" Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection). Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment (Option 1). (Option 2) Wiping front to back after urination may help prevent Escherichia coli (a common UTI pathogen found in stool) from contaminating the urethra. Reviewing toileting hygiene is important but does not help assess current symptoms. (Option 3) Urinary frequency and nocturia are common during pregnancy. However, the nurse should not focus on the normalcy of urinary frequency since the client has reported additional symptoms (eg, dysuria). (Option 4) Pregnancy predisposes clients to UTIs. Furthermore, assessing for history of UTI does little to address the client's current symptoms. Educational objective: Urinary tract infections are common during pregnancy. If the client reports signs and symptoms of cystitis, the nurse's priority is to rule out ascending infection (ie, pyelonephritis), which would require hospitalization and IV antibiotics.

The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement by the client indicates an appropriate understanding about weight gain? 1. "I should gain 10-15 lb (4.5-6.8 kg) during the first trimester." 2. "I should gain a total of about 30 lb (13.6 kg) during my pregnancy." 3. "I should gain no more than 0.5 lb (0.2 kg) per week during the third trimester." 4. "If I gain <20 lb (9.1 kg) during pregnancy, it will be easier to lose weight postpartum."

2 Appropriate weight gain during pregnancy decreases risks to the client and fetus. Expected weight gain is determined by prepregnancy BMI. Underweight clients need to gain more weight (1 lb [0.5 kg] per week) during the second and third trimesters of pregnancy than obese clients (0.5 lb [0.2 kg] per week). However, weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. With a prepregnancy BMI of 21 kg/m2, this client has an appropriate weight and should gain 25-35 lb (11.3-15.9 kg) over the course of the pregnancy (Option 2). (Option 1) Weight gain during the first trimester should be approximately 1.1-4.4 lb (0.5-2.0 kg). A 10 lb (4.5 kg) weight gain during the first three months of pregnancy would be excessive for any client. (Option 3) A client of appropriate weight should gain approximately 1 lb (0.5 kg) per week during the second and third trimesters of pregnancy. A weight gain of only 0.5 lb (0.2 kg) per week is recommended for obese clients. (Option 4) A weight gain of <20 lb (9.1 kg) during pregnancy is inadequate for a client of appropriate weight. Restricting weight gain increases the fetus' risk for low birth weight (<5.5 lb [2500 g]) and preterm birth. Educational objective: Appropriate weight gain during pregnancy decreases risks to the client and fetus. Weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. The optimal total weight gain during pregnancy is determined by the client's prepregnancy BMI.

The nurse is assessing a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first? 1. "I am not sleeping as well due to cramps in my calves at night." 2. "I have noticed less kicking movements as the baby grows bigger." 3. "Over the last few weeks, I have not been able to wear any of my shoes." 4. "Sometimes I feel short of breath after walking up a flight of stairs."

2 Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However, fetal movements should not decrease as the fetus increases in size. Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal death (Option 2). The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (eg, nonstress test). (Option 1) Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying pressure to nerves affecting calf muscles. Home interventions include stretching legs, massaging calves, and increasing fluid intake. (Option 3) Dependent edema in the lower extremities is common in the third trimester due to decreased venous return (gravid uterus pressure on vena cava), especially with prolonged sitting/standing. This is not a priority over decreased fetal movement. (Option 4) As the uterus rises in the third trimester, the diaphragm is prevented from allowing full lung expansion, causing dyspnea, especially with exertion. Educational objective: Fetal movement is a sign of fetal health and represents an intact fetal central nervous system. The nurse should educate clients that fetal movements do not decrease in the late third trimester and prioritize assessment of clients reporting decreased fetal movement.

The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action? 1. Document fetal presentation as breech 2. Document fetal presentation as cephalic 3. Elevate the fetal presenting part away from the prolapsed cord 4. Request that the health care provider confirm fetal presentation

2 The nurse is most likely palpating the diamond-shaped anterior fontanelle of the fetal head, which is in cephalic (ie, head down) presentation. Therefore, the nurse should document the fetal presentation as cephalic. The posterior fontanelle is triangular and separated from the anterior fontanelle by the sagittal suture. By identifying the location of these fetal skull landmarks, an experienced examiner can determine the fetal head position, or the direction the occiput is facing. (Option 1) With breech presentation, the fetal buttocks, legs, or feet may be palpated. Fetal buttocks do not feel as round, smooth, or firm as the head during vaginal examination. Although the anus could be mistaken for a fontanelle, the anal sphincter feels firmer to palpation than a fontanelle and is circular, rather than triangular or diamond shaped. (Option 3) A prolapsed cord would feel soft and rubbery on palpation and may be pulsating. If the cord is prolapsed, an emergency cesarean delivery is usually required. (Option 4) Palpating the anterior fontanelle should reassure the nurse that the fetus is in a cephalic presentation, so there is no indication for informing the health care provider. Educational objective: Fetal head position can be determined by the sutures and fontanelles (eg, diamond-shaped anterior fontanelle) of the fetal skull.

A 14-year-old client confides to the school nurse that she is about 22 weeks pregnant and has not had prenatal care. Which topics are most important and priorities for the nurse to discuss with the client in anticipation of referral for prenatal care? Select all that apply. 1. Adoption planning 2. Family and social support 3. Future education plans 4. Nutrition and prenatal vitamins 5. Sexual abuse

2, 4, 5 The nurse should ascertain potential risks to the client and her baby due to teenage pregnancy. Lack of family/social support or fear of social discrimination may prevent the client from obtaining prenatal care (Option 2). Poverty, dangerous living conditions, and exposure to teratogens (eg, tobacco, alcohol, illicit drugs) may place the client at risk for complications. Adolescents are at risk for poor nutritional status and poor pregnancy weight gain, which can have deleterious effects on the baby (eg, small for gestational age, low birth weight) (Option 4). They are also less likely to take prenatal vitamins with folic acid. Adolescents who are pregnant should be evaluated for sexual abuse; girls age 11-14 do not usually seek sexual relationships, and the pregnancy may be evidence of abuse (Option 5). (Option 1) Adoption planning is not necessary at this first assessment, although the topic may be addressed later in collaboration with a social worker. (Option 3) The younger adolescent (age <16) is emotionally and developmentally immature and may be resistant to planning for the future. Education planning may be approached at subsequent encounters, but it is not a priority for the client and the baby's health at this time. Educational objective: Adolescents are at increased risk for obstetrical complications that can contribute to neonatal morbidity and mortality. Factors such as lack of family support, sexual abuse, and poor nutritional status can negatively impact the pregnancy.

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply. 1. Cervical softening on examination 2. Fetal heart tones detected by Doppler device 3. Positive serum human chorionic gonadotropin test 4. Report of fetal movement felt by client 5. Visualization of fetus by ultrasound

2, 5 Positive (diagnostic) signs of pregnancy represent conclusive evidence of pregnancy and cannot be attributed to any other etiology. These signs include a discernible fetal heartbeat heard by Doppler device, ultrasound visualization of the fetus, and fetal movement palpated or observed by the health care provider (HCP) (Options 2 and 5). Presumptive (subjective) signs of pregnancy are self-reported by the client (eg, breast tenderness, nausea, amenorrhea). These signs may be related to other medical conditions and therefore cannot be considered diagnostic of pregnancy. Probable (objective) signs of pregnancy are observed by the HCP during assessment and examination (eg, cervical changes, positive pregnancy test). Combined with subjective signs, objective signs may be more indicative of pregnancy but may still have alternate causes. (Option 1) Cervical softening is an objective sign of pregnancy as it may also be caused by other conditions that result in pelvic congestion (eg, use of hormonal contraceptives, uterine tumors). (Option 3) A positive serum pregnancy test, which reports elevated levels of human chorionic gonadotropin, is considered an objective sign of pregnancy. Gestational trophoblastic disease can also cause positive results. (Option 4) The client's perception of fetal movement, known as quickening, is a presumptive sign of pregnancy. Educational objective: Positive signs of pregnancy represent conclusive evidence of pregnancy. These signs include ultrasound visualization of the fetus, a distinguishable fetal heartbeat heard by Doppler device, and fetal movement palpated or observed by the health care provider.

The nurse receives report on 4 first-trimester pregnant clients. Which client should the nurse assess first? 1. Client with hydatidiform mole reporting dark brown vaginal discharge 2. Client with hyperemesis gravidarum reporting excessive vomiting and weight loss 3. Client with suspected ectopic pregnancy reporting abdominal and shoulder pain 4. Client with threatened miscarriage who says, "I am a Jehovah's Witness."

3 An ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterine cavity, frequently in the fallopian tubes. Clients with ectopic pregnancies may report a positive pregnancy test, vaginal spotting/bleeding, and/or abdominal pain. If untreated, continued growth can lead to fallopian tube rupture, resulting in hemorrhage and hemodynamic compromise. Intra-abdominal bleeding can lead to referred shoulder pain, a classic sign of diaphragm irritation. Ruptured ectopic pregnancy requires emergency surgical intervention and hemodynamic support (eg, IV fluids, blood transfusion) (Option 3). (Option 1) In clients with hydatidiform mole or "molar pregnancy," the fetus is replaced by edematous, cystic chorionic villi. Clients experiencing molar pregnancy should anticipate intermittent, dark brown vaginal discharge until the pregnancy is evacuated. (Option 2) Clients with hyperemesis gravidarum have excessive nausea and vomiting and weight loss, often requiring fluid replacement and antiemetic therapy. The condition is not usually life-threatening and does not take priority over ruptured ectopic pregnancy. (Option 4) Clients who are Jehovah's Witnesses do not allow blood transfusions due to religious beliefs. Clients with threatened miscarriage usually report spotting but have a closed cervical os. Heavier bleeding requiring a blood transfusion may be more common with inevitable or incomplete miscarriages. Educational objective: Ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterus, often in the fallopian tubes. Rupture of an ectopic pregnancy results in hemorrhage and requires emergency surgery. Shoulder pain in a client with ectopic pregnancy indicates intra-abdominal bleeding from a rupture.

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. Complete hourly pain assessments using a numeric pain scale 2. Document that the client appears to be experiencing minimal pain 3. Monitor for nonverbal signs of ineffective coping with labor 4. Recognize that the client's stoicism is ineffective coping with labor

3 Developing cultural competence (ie, understanding, attitudes, and abilities acquired to meet the needs of culturally diverse clients) helps the nurse provide culturally sensitive labor support and pain management. Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication. It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management. In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping (Option 3). Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief. (Option 1) Pain assessments using a numeric pain scale do not adequately assess coping during labor. Furthermore, the appropriate frequency of pain assessments varies and may be influenced by labor progress and the client's preferred pain-relief method. (Options 2 and 4) Stoicism and lack of outward expressions of pain do not indicate that the client is not experiencing pain, nor should they be misidentified as ineffective coping. Educational objective: A client's cultural background may affect expression of pain during labor. In Japanese culture, silence and nonverbal communication may be valued over overt forms of communication. The nurse should assess the client's coping and monitor for nonverbal cues of ineffective coping (eg, writhing, screaming, panicking).

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

4 A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. (Option 1) Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. (Option 2) Complete inversion of the uterus presents with a large, red mass protruding from the introitus. (Option 3) Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding. Educational objective: Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.

What is an appropriate nursing intervention after the birth of a newborn with anencephaly? 1. Instruct the parents that visitors should be restricted 2. Provide information to the parents about genetic counseling 3. Refer the parents to a perinatal loss support group 4. Wrap the newborn in warm blankets for the parents to hold

4 Anencephaly is a severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero. Many newborns with anencephaly are stillborn, and those born alive are not compatible with life. Comfort care for the newborn and emotional support for the family is priority at the time of birth. Drying, bundling, and placing the newborn skin-to-skin provides warmth, and administering oxygen may decrease discomfort to the newborn. Allowing the family to hold the newborn will assist with the grieving process. (Option 1) The nurse should ensure the family's privacy but should also consider the parents' preferences, as they may benefit from the support of friends and family, a religious leader, or a hospital chaplain. (Option 2) Information about future genetic and preconception counseling is important discharge teaching as NTDs may be related to both genetic and environmental (eg, folic acid deficiency) factors. However, this intervention is not appropriate at this time. (Option 3) The parents may benefit from a perinatal loss support group, and this referral should be made prior to discharge. However, immediately after birth is probably not the most appropriate time to provide information about this resource. Educational objective: Anencephaly is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. The newborn may be stillborn or born alive, although death occurs shortly thereafter. Nurses should facilitate a therapeutic environment for grieving parents and provide newborn comfort care such as warmth and oxygen.

A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. Which action should the nurse take first? 1. Administer normal saline fluid bolus 2. Ask about any prenatal complications 3. Initiate fetal heart rate monitoring 4. Tilt the backboard to one side

4 During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury (Option 4). Manifestations of aortocaval compression (eg, hypotension, pallor, dizziness) may mimic those of other complications of trauma. It is therefore critical to reassess blood pressure after uterine displacement to identify persistent hypotension, which may indicate hemorrhage caused by trauma (eg, placental abruption). (Option 1) An IV fluid bolus of isotonic fluids (eg, lactated Ringer solution) to correct hypotension is appropriate if position changes do not relieve symptoms or hemorrhage is suspected. Client positioning should be considered first. (Option 2) Assessing medical and obstetric history is important when planning care for a pregnant client, but immediate physical needs are the priority. (Option 3) The nurse should first reposition the client to address a potential cause of hypotension (aortocaval compression), which can affect blood flow to the fetus, and then initiate fetal monitoring. Educational objective: During stabilization of a pregnant client after trauma, uterine displacement is the first step to prevent/correct supine hypotension and promote blood circulation to the fetus. A lateral tilt of the backboard can correct aortocaval compression while protecting the client from further spinal injury.

The nurse performs initial assessments of four clients in a prenatal clinic. Which client findings are abnormal and require further assessment? 1. Client at 9 weeks gestation with a normal BMI and a weight gain of 2 lb (1 kg) from pre-pregnancy weight 2. Client at 15 weeks gestation with headaches relieved by acetaminophen 3. Client at 19 weeks gestation with bleeding gums after brushing and flossing teeth 4. Client at 20 weeks gestation with an increase in diastolic blood pressure of 15 mm Hg since last visit

4 Physiologic decreases in systemic vascular resistance during pregnancy cause a steady, slight decrease in blood pressure (BP) beginning in the first trimester and reaching the lowest point around 24-32 weeks gestation. In the third trimester, BP gradually returns to pre-pregnancy baseline. Monitoring BP during pregnancy assists in the detection of hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, preeclampsia, eclampsia). Some clients with only mildly elevated BP may develop eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/early-pregnancy measurements, even in the absence of hypertension (ie, ≥140/90 mm Hg), is a deviation from normal physiologic BP responses in pregnancy and requires further assessment for other signs/symptoms (eg, proteinuria, headache, right upper quadrant pain) (Option 4). (Option 1) Early in the first trimester, minimal weight gain (ie, 1-4 lb [0.5-1.8 kg]) is expected for clients with a normal BMI. (Option 2) Occasional headaches relieved by acetaminophen may be normal for some pregnant clients. Severe, frequent, or worsening headaches require further assessment. (Option 3) Hyperemic gums are common in pregnancy and may be susceptible to mild bleeding during brushing. Gentle cleaning with a soft toothbrush may help prevent bleeding. Educational objective: Physiologic decreases in systemic vascular resistance cause a steady, slight decrease in blood pressure (BP) beginning in the first trimester and reaching its lowest point around 24-32 weeks gestation. An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/early-pregnancy measurements requires further assessment.

A nurse is measuring a uterine fundal height for a client who is at 36 weeks gestation in supine position. The client suddenly reports dizziness and the nurse observes pallor and damp, cool skin. What should the nurse do first? 1. Assess fetal heart rate and pattern 2. Assess heart and lung sounds 3. Notify the health care provider (HCP) immediately 4. Reposition the client into a lateral position

4 Supine hypotensive syndrome occurs when the weight of the abdominal contents compresses the vena cava causing decreased venous return to the heart. This results in low cardiac output (maternal hypotension) and reflex tachycardia. Manifestations include dizziness, pallor, and cold and clammy skin. The client should be immediately repositioned onto the right or left side until the symptoms subside. Prevention of this condition includes using a wedge under the client's hip while in a supine position. (Option 1) Decreased maternal cardiac output can result in decreased placental blood flow and fetal heart rate (FHR) abnormalities. FHR assessment also follows after the client is placed in the right or left lateral position. (Option 2) When supine hypotension is suspected, the client should first be placed in a lateral position. Blood pressure and pulse are checked to confirm the diagnosis. Assessing lung and heart sounds is not a priority. (Option 3) The HCP is notified after placing the client in a lateral position and completing the assessment. Educational objective: Supine hypotensive syndrome is usually seen in the third trimester of pregnancy when the weight of the uterine contents compresses the inferior vena cava. The resultant maternal hypotension is best treated initially by turning the client to the right or left side to relieve pressure on the vena cava.

A pregnant client in the first trimester tells the clinic nurse she will be traveling to an area with a known Zika virus outbreak and expresses concern regarding disease transmission. Which statement by the nurse is most appropriate? 1. "If you experience Zika symptoms, notify your health care provider." 2. "Take precautions against mosquito bites throughout the trip." 3. "You are not far enough along for the Zika virus to affect your baby." 4. "You should consider postponing your trip until after you have the baby."

4 Zika virus is transmitted via mosquitoes, sexual contact, and infected bodily fluids. Zika causes viral symptoms (eg, low-grade fever, arthralgias) and has been shown to cause microcephaly, developmental dysfunction, and encephalitis in babies born to Zika-infected women. Women who are attempting to conceive and those who are pregnant are encouraged to avoid travel to areas affected by Zika until after birth (Option 4). For clients currently living in a Zika-affected area, proper mosquito precautions (eg, insect repellant containing DEET) and safe sex practices (eg, barrier methods) should be utilized, and routine Zika testing may be provided. (Option 1) Although this statement is true, it does not provide education on avoiding Zika infection. Waiting until symptoms are present does not address preventing fetal exposure and possible birth defects. (Option 2) Current guidelines recommend that pregnant women avoid travel to Zika-affected areas completely. In addition, mosquitoes are not the only mode of transmission for the virus. (Option 3) Zika virus can affect women in all stages of pregnancy. Educational objective: Zika infection in a pregnant woman can cause birth defects and developmental dysfunction. Current guidelines recommend that pregnant women avoid travel to Zika-affected areas.

A client indicates the desire to become pregnant. Which of the following are important preconception education topics for the nurse to provide? Select all that apply. 1. Aim for BMI of 18.5-24.9 kg/m2 2. Avoid alcohol consumption and tobacco products 3. Ensure daily intake of 400 mcg of folic acid 4. Obtain testing for rubella immunity 5. Schedule dental wellness appointment

ALL Preconception counseling assesses for pregnancy risk factors and implements appropriate interventions to promote a healthy pregnancy. Some behaviors the client may begin independently include eating a nutritious diet; exercising; abstaining from alcohol, tobacco, and illicit drugs; and taking folic acid supplements. Obesity (BMI >30 kg/m2) during pregnancy is associated with an increased risk for fetal/maternal complications (eg, gestational diabetes, hypertension, cesarean birth). Achieving a normal BMI (18.5-24.9 kg/m2) is optimal (Option 1). No amount of alcohol is considered safe in pregnancy; complete abstinence from alcohol is recommended to avoid fetal alcohol syndrome. Smoking cessation is encouraged due to its association with fetal growth restriction; illicit drugs may also cause fetal harm (Option 2). Folic acid supplementation of at least 400 mcg per day for 3 months before pregnancy is recommended to reduce the incidence of neural tube defects (Option 3). Neural tube development begins around the third week following conception, before a woman may realize that she is pregnant. Finally, clients should visit their health care provider to discuss pregnancy's effect on certain health conditions (eg, asthma, diabetes) and check rubella immunity (Option 4). Rubella vaccination should be given if the client is nonimmune, and pregnancy should be avoided for at least 4 weeks after vaccination. Regular visits with a dentist can help prevent periodontal disease, which is associated with poor pregnancy outcomes (eg, preterm birth, low birth weight) (Option 5). Educational objective: Preconception care improves pregnancy outcomes and includes folic acid supplementation; regular dental care; updated vaccinations; avoidance of alcohol, smoking, and illicit drugs; and achieving a normal weight.