Ch 10 PrepU: Nursing Care Changes in Pregerancy
The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective?
"I will need to take iron supplementation throughout my pregnancy even if I am not anemic." Iron is recommended for all pregnant women because it is almost impossible for the pregnant woman to get what is required from diet alone, especially after 20 weeks' gestation when the requirements of the fetus increase. Pregnant women can get many nutrients from seafood including phosphorus, but there are specific recommendations about types of fish to avoid because of the risk of mercury poisoning. Milk production actually requires higher levels of zinc, which can be obtained from a healthy diet. Calcium requirements do not increase above prepregnancy levels during pregnancy because calcium absorption is enhanced during pregnancy. It can be unsafe for the pregnant woman to eat anything she wants and gain too much weight. A woman who gains too much weight during pregnancy is at risk for delivering a macrosomic baby.
A client in her second trimester of pregnancy arrives at the health care facility for a routine follow-up visit. The nurse is required to educate the client so that the client knows what to expect during her second trimester. Which information should the nurse offer?
"You will experience quickening, and you will actually feel the baby." The nurse should inform the client that quickening occurs in the second trimester. The client will be able to physically feel the fetal movements, which will help her bond with her developing fetus. Physical discomfort actually starts to increase in the third trimester as the fetus grows rapidly. The client feels conscious of the changes taking place in her body due to her pregnancy primarily in the first trimester, not the second. The client is likely to have mood swings in the first trimester of the pregnancy, which can be very overwhelming for the client as well as her partner.
The client is presenting with presumptive or subjective symptoms of pregnancy. Given her symptoms and age, asking about sexual activity is the most appropriate question. Whether she is taking an oral contraceptive will not assist in identifying the cause of her symptoms. If she has vaginal itching, the underlying cause of her symptoms needs to be identified before treatment can be prescribed.
A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client?
"What you are feeling are called Braxton Hicks contractions. They are considered practice, painless, and intermittent contractions during pregnancy."
A client is about 16 weeks' pregnant and is concerned because she feels her "abdomen" contracting. She calls the primary care provider's office and speaks to the nurse. What is the nurse's most appropriate response to this client's concern?
There are only three documented or positive signs of pregnancy: 1) demonstration of a fetal heart separate from the mother's, 2) fetal movements felt by an examiner, and 3) visualization of the fetus by ultrasound. The absence of a period is an example of a presumptive symptom, which is a symptom that, when taken as a single entity, could easily indicate other conditions.
A client who has just given a blood sample for pregnancy testing in the health care provider's office asks the nurse what method of confirming pregnancy is the most accurate. The nurse explains the difference between presumptive symptoms, probable signs, and positive signs. What should the nurse mention as an example of a positive sign, which may be used to diagnose pregnancy?
Home pregnancy tests are 95% reliable if used according to the instructions on the kit. In fact, some can detect hCG within 1 day after a missed period. These tests often give a false negative, not false positive, reading. Results can be tested with the first voided specimen of the day.
A client who suspects she is pregnant asks the nurse about the accuracy of home pregnancy tests. The nurse would tell the client that:
The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. Slight bleeding after a pelvic exam in a pregnant woman is common due to the vascularity of her cervix during pregnancy. Suggesting a bleeding disorder is frightening and not substantiated by the data. Bleeding is not a normal finding during pregnancy and losing the mucus plug occurs at the end of pregnancy, just prior to labor.
A pregnant client at 24 weeks' gestation calls the clinic crying after a prenatal visit, where she had a pelvic exam. She states that she noticed blood on the tissue when she wiped after voiding. What initial statement by the nurse would explain this finding?
The client is in the first trimester and is most likely to experience urinary frequency as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids are more common during the later stages of pregnancy.
A primiparous client is being seen in the clinic for the first prenatal visit. It is determined that the client is 11 weeks' pregnant. The nurse develops a teaching plan to educate the client about what they will most likely experience during this period. Which possible effect should the nurse include?
Hormone levels of a woman indicate that the corpus luteum stopped functioning and releasing progesterone after 5 weeks. The nurse would recognize that which scenario is the expected outcome?
A spontaneous abortion (miscarriage) would occur. If the corpus luteum fails to produce progesterone for approximately 6 to 7 weeks, a spontaneous abortion (miscarriage) will occur. After 7 weeks, the placenta will produce enough progesterone to sustain the pregnancy. There is no connection between multifetal pregnancies and the corpus luteum not functioning long enough in progesterone production.
2+ protein in urine During pregnancy, there may be a slight amount of glucose found in the urine due to the fact that the kidney tubules are not able to absorb as much glucose as there were before pregnancy. However, there should be minimal protein in the urine. A specific gravity of 1.010 and a straw- like color are both normal findings.
A urinalysis is done on a client in her third trimester. Which result would be considered abnormal?
The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?
A urine pregnancy test is considered a probable sign of pregnancy as the hCG may be from another source other than pregnancy. Fatigue, amenorrhea, and vomiting are presumptive or possible signs of pregnancy and can also have other causes.
The nurse has messages from four pregnant woman. Which woman would the nurse call back and ask for more data first?
All clients will be called back in situations where further data collection and instruction are needed. Immediate assessment with further data is needed from the client with clear, vaginal fluid from the vagina. This client will be called back first. Foot swelling, leg cramps, and heartburn are within the normal expectations of pregnancy and the nurse would ask for more information on the conditions.
The nurse obtains a human chorionic gonadotropin (hCG) level from a woman who thinks that she is pregnant. Which result would the nurse identify as a positive pregnancy result?
An hCG level lower than 5 mIU/mL (5 IU/l) is considered negative for pregnancy, and anything higher than 25 mIU/mL (25 IU/l) is considered positive for pregnancy.
The nurse-midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell sign. Which description illustrates this alteration?
At about the 8th week of gestation, the cervix softens, a probable sign known as Goodell sign. The cervix also looks blue or purple when examined; this is Chadwick sign, and may occur as early as the 6th week of pregnancy. At about 6 weeks, the lower uterine segment softens, a probable sign called Hegar sign. A softening of the uterine fundus, where the embryo has implanted, also occurs by about the 7th week, and the fundus enlarges by the 8th week.
85 bpm During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per minute.
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks' pregnant. The nurse would expect this woman's heart rate to be approximately:
A woman in her second trimester comes to the clinic for a routine follow-up visit. The woman's prepregnancy blood pressure was 112/70 mm Hg. On this visit, the woman's blood pressure is 104/64 mm Hg. The nurse would interpret this finding as suggestive of which event?
Blood pressure, especially the diastolic pressure, declines slightly during pregnancy as a result of peripheral vasodilation caused by progesterone. It usually reaches a low point mid-pregnancy and thereafter increases to prepregnancy levels until term. During the first trimester, blood pressure typically remains at the prepregnancy level. During the second trimester, the blood pressure decreases 5 to 10 mm Hg and thereafter returns to first-trimester levels. This decrease in blood pressure begins at about 7 weeks' gestation and persists until 32 weeks' gestation, when it begins to rise to prepregnancy levels. The client's blood pressure suggests a normal finding related to peripheral vasodilation from progesterone.
The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting?
By 20 weeks' gestation, muscles of the abdominal wall may begin to separate (diastasis recti) and not return to normal approximation until several weeks after childbirth. The term diastasis recti does not refer to the raising of the uterus into the abdomen, relaxation of the kidneys, or movement of the bladder.
A pregnant woman questions the nurse about changes she is noticing in her breasts and is concerned if they are normal. Which reported changes would the nurse recognize as normal breast changes during pregnancy? Select all that apply.
Changes in breast tissue during pregnancy begin early and continue until delivery. Striae or stretch marks appear, the areola darkens, and the breast tissue may feel nodular from the stimulated glandular production and the Montgomery glands (Montgomery tubercles) produce secretions to lubricate the nipples. A red rash is not a normal finding.
A local change that often occurs in the respiratory system is marked congestion, or "stuffiness," of the nasopharynx, a response to increased estrogen levels. A pregnant client may worry this stuffiness indicates an allergy or a cold. Rather, it is a symptom of pregnancy. The use of any medication during pregnancy needs to be evaluated to make sure that it is safe for the client to use.
During a visit to the clinic, a client in the first trimester tells the nurse, "My nose is so stuffy, lately. Could I have a cold?" Which response by the nurse is appropriate?
During a vaginal exam, the nurse notes that the lower uterine segment is softened. How should the nurse document this finding?
Hegar sign refers to the softening of the lower uterine segment or isthmus. Bluish coloration of the cervix is termed Chadwick sign. Goodell sign refers to the softening of the cervix. Ortolani sign is a maneuver done to identify developmental dysplasia of the hip in infants.
What would the nurse recommend to a pregnant client at 35 weeks' gestation who reports irregular contractions and lower backache?
If a client is less than 37 weeks and having contractions that will not go away, she may be in preterm labor and this needs to be reported. The first thing for her to do is lie down and rest to see if the contractions go away. Lower backache and cramping or pain need to be taken seriously and reported to the health care provider if they persist.
pressure of the gravid uterus on the vena cava. The client is describing symptoms of supine hypotension syndrome, which occurs when the heavy gravid uterus falls back against the superior vena cava in the supine position. The vena cava is compressed, reducing venous return, cardiac output, and blood pressure, with increased orthostasis. The increased blood volume and physiologic anemia are unrelated to the client's symptoms. Pressure on the diaphragm would lead to dyspnea.
In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse explains that this is due to:
melasma (chloasma)
Increased pigmentation on the face of some pregnant women is called:
The nurse has just informed a client that the pregnancy test is positive and the client will need further assessment to determine the complete status of the situation. Which initial emotional response does the nurse expect the client to exhibit?
Initially, the pregnant client commonly experiences ambivalence, with conflicting feelings at the same time. Introversion heightens during the first and third trimesters when the client's focus is on behaviors that will ensure a safe and healthy pregnancy outcome. Acceptance usually occurs during the second trimester. Emotional lability (mood swings) is characteristic throughout a pregnancy.
The client at 18 weeks' gestation states, "I feel a fluttering sensation, kind of like gas." The nurse understands that the client is describing what occurrence?
The fluttering sensation that can be confused with gas is called "quickening." In the 2 weeks leading up to the 20-week mark, she may feel "flutters" that she may confuse with gas. Lightening is the descent of the presenting part of the fetus into the pelvis. Placenta previa is the implantation of the placenta so that it covers part or all of the cervical os. Linea nigra is a hyperpigmented line that appears on the maternal abdomen between the symphysis pubis and top of the fundus.
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?
Meats are the best source of heme-rich iron and should be included in her diet if she is not following a vegetarian diet. Grains and legumes are non-heme iron sources. Dairy products will add various vitamins and calcium to the diet.
The nursing student is preparing a pamphlet that will illustrate the various hormones involved with a pregnancy. Which hormone should the nurse indicate is responsible for the let-down of breast milk in this pamphlet?
Oxytocin, produced by the posterior pituitary gland, stimulates uterine contractions and the release of milk in the mammary glands (let-down reflex). Prolactin, a pituitary hormone, triggers and sustains milk production. Progesterone, produced by the corpus luteum and placenta, prepares the endometrium for implantation of the fertilized ovum, develops the mammary glands, and maintains the pregnancy. Estrogen is a female sex hormone produced by the ovaries and placenta.
Which information provided by a client would be considered a presumptive sign of pregnancy?
Presumptive signs of pregnancy are things reported by the woman to the health care provider and occur early in pregnancy. Breast tenderness is a common sign reported by women in early pregnancy but is not a definitive sign. Reports of increased hunger and weight gain could be caused by any disorder or could be normal responses to eating cycles. Ballottement occurs late in the pregnancy and is a probable sign.
Which change related to the vital signs is expected in pregnant women?
Pulse and temperature often increase, while lung space is decreased in pregnant women. It is common for blood pressure to decrease during pregnancy.
A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation (dilatation) and enlargement of the birth canal. What is this hormone?
Relaxin, secreted by the corpus luteum of the ovary as well as the placenta, is responsible for helping to inhibit uterine activity and to soften the cervix and the collagen in joints. Softening of the cervix allows for dilation (dilatation) at birth; softening of collagen allows for laxness in the lower spine and so helps enlarge the birth canal. The effect of estrogen is to cause breast and uterine enlargement. Progesterone has a major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breasts for lactation. Human placental lactogen (hPL), also known as human chorionic somatomammotropin, serves as an antagonist to insulin, making insulin less effective and thereby allowing more glucose to become available for fetal growth.
The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The growing fetus is displacing the intestines and interfering with peristalsis, delaying the passage of fecal matter and resulting in constipation. This is common and expected; however, the client should take measures to prevent hemorrhoids that can occur as the result of the pressure and straining. Progesterone, not hCG, can delay gastric emptying and decrease peristalsis.
A pregnant client is concerned because she has noticed that she is developing brown blotches on her forehead and nose. The nurse realizes that the client understood the teaching about this problem when the client makes which statement?
The brown blotches the client is experiencing on her face is called melasma (chloasma) or the "mask of pregnancy." Hyperpigmentation is one of the skin changes that pregnant women experience. This condition may be permanent or may regress between pregnancies. Linea nigra is the darkened line in the middle of the abdomen seen on some pregnant women. Melasma does not go away in the third trimester and there is no evidence that it will get worse with each pregnancy.
A pregnant client at 24 weeks' gestation calls the clinic crying after a prenatal visit, where she had a pelvic exam. She states that she noticed blood on the tissue when she wiped after voiding. What initial statement by the nurse would explain this finding?
The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. Slight bleeding after a pelvic exam in a pregnant woman is common due to the vascularity of her cervix during pregnancy. Suggesting a bleeding disorder is frightening and not substantiated by the data. Bleeding is not a normal finding during pregnancy and losing the mucus plug occurs at the end of pregnancy, just prior to labor.
A pregnant client is visiting the clinic and complains about the tiny, blanched, slightly raised end arterioles on her face, neck, arms, and chest. The nurse should explain that these are normal during pregnancy and are referred to as:
The dilated arterioles that occur during pregnancy are due to the elevated level of circulating estrogen and are called telangiectasias. An epulis is a red raised nodule on the gums that may develop at the end of the first trimester and continue to grow as the pregnancy progresses. The linea nigra is a pigmented line extending from the symphysis pubis to the top of the fundus during pregnancy. Striae gravidarum (stretch marks) are slightly depressed streaks that commonly occur over the abdomen, breast, and thighs during the second half of pregnancy.
The nurse is assessing a 37-year-old woman, pregnant with twins in her second trimester, and notes the following over the past 3 visits: blood pressure 128/88, 134/90, and 130/86. Which nutritional supplement should the nurse suggest the client take?
The elevated blood pressures indicate the client is possibly developing gestational hypertension. This increases the risk of developing preeclampsia. Current research has demonstrated that calcium supplementation during pregnancy may reduce the risk of preeclampsia. Excessive levels of vitamin A may cause birth defects. Iron supplementation is used to fortify blood cell formation and decrease anemia. Lactase supplementation aids in the digestion of dairy.
All women have Montgomery glands (Montgomery tubercles) that secrete lubricant for the nipples. They become more prominent during pregnancy and help to prepare the nipples for breastfeeding. The bumps are not specific to pregnancy and are not a sign of cancer. They are not the result of stretching.
The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?
Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). objective - hydatidiform mole and ultrasound
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply.
During the third trimester, the mother begins to shop for clothing and nursery furniture, which is nesting. Additionally, she will experience urinary frequency due to the gravid uterus pushing down on the bladder. Lastly, the couple needs to attend childbirth classes to better understand what to expect, as well as providing social contact with other parents going through the same thing.
The nurse is holding an education class for clients in their third trimester and their partners. What information would she share with them in preparation for the birth of their child? Select all that apply.
Lightening refers to the descent of the fetal head into the pelvis and engagement. With this descent, pressure on the diaphragm decreases, easing breathing, but pressure on the bladder increases, leading to urinary frequency. Dysuria might indicate a urinary tract infection. Constipation may occur throughout pregnancy due to decreased peristalsis, but it is unrelated to lightening.
The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. What will the mother likely experience at that time?
Positive signs of pregnancy are diagnostic, meaning nothing else can elicit that sign except pregnancy. What is the earliest positive sign of pregnancy?
The positive sign that can be elicited earliest in the pregnancy is visualization of the gestational sac or fetus. With transvaginal ultrasound, the gestational sac can be seen as early as 10 days after implantation.
The nurse cares for a pregnant client at the first prenatal visit and reviews expected changes that will occur during pregnancy. Which information will the nurse include in the education?
The pregnant woman can experience a blood volume increase by approximately 40% to 50% above prepregnancy levels by the end of the third trimester. Pregnancy results in an increased respiratory rate to provide oxygen to both the mother and fetus. Hemoglobin levels are usually low during pregnancy because of hemodilution of red blood cells, which is termed physiologic anemia of pregnancy. Blood pressure usually reaches a low point mid-pregnancy and, thereafter, increases to prepregnancy levels by the third trimester.
Which effect would the nurse identify as a normal physiologic change in the renal system due to pregnancy?
The renal pelvis becomes dilated during pregnancy, possibly due to the effect of progesterone on smooth muscle. The glomerular filtration rate increases during pregnancy. The kidneys enlarge during pregnancy. The ureters elongate, widen, and become more curved above the pelvic rim.
Probable signs of pregnancy include objective data such as the Goodell sign, which is cervical softening. Another probable sign is ballottement, which is when the examiner pushes against the uterine wall and it bounces back. Breast tenderness and amenorrhea are presumptive signs and visualization of the gestational sac is a positive sign of pregnancy.
What are the probable signs of pregnancy that would be noted in a woman? Select all that apply.
Fetal heart sounds are audible with a Doppler at 10 to 12 weeks' gestation but cannot be heard through a stethoscope until 18 to 20 weeks' gestation. Fetal movements can be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around 20 weeks' gestation. The fetal outline is also palpable around 20 weeks' gestation.
Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to:
Which interventions would a pregnant client be taught regarding dietary restrictions during pregnancy? Select all that apply.
While pregnant, women must adhere to certain rules regarding food preparation and storage. The woman should discard foods that have been left out at room temperature for more than 2 hours, wash raw fruits and vegetables with hot water and a mild soap, and avoid drinking raw or unpasteurized milk. Soft cheeses should be avoided. There is no need to limit beef during pregnancy.
Which of the following changes, with highest priority, should the nurse teach a pregnant client to report to the health care provider as soon as possible?
abdominal pain coming and going during the third trimester Any abdominal pain needs to be reported to the health care provider ASAP. This could be a sign of preterm labor and needs to be addressed. Vomiting during the first trimester is normal. Heartburn is caused by the shifting of abdominal organs. Frequent urination is the result of increased pressure on the bladder.
During a routine antepartal visit, a pregnant woman reports a white, thick vaginal discharge. What would the nurse do next?
ask the woman if she is having any itching or irritation Although vaginal secretions increase during pregnancy, the nurse would need to ascertain if this discharge is the normal leukorrhea of pregnancy or if it is a monilial vaginitis, which is common during pregnancy. The nurse needs additional information to conclude that the woman's report is normal. A culture may or may not be necessary. There is no evidence to suggest that her membranes have ruptured.
During an exam, the nurse notes that the blood pressure of a client at 22 weeks' gestation is lower, and her heart rate is 12 beats per minute higher than at her last visit. How should the nurse interpret these findings?
both findings are normal at this point of the pregnancy A pregnant woman will normally experience a decrease in her blood pressure during the second trimester. An increase in the heart rate of 10 to 15 beats per minute on average is also normal, due to the increased blood volume and increased workload of other organ systems. Hormonal changes cause the blood vessels to dilate, leading to a lowering of blood pressure.
A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?
fetal movement felt by examiner The positive signs of pregnancy are fetal image on a sonogram, hearing a fetal heart rate, and examiner feeling fetal movement. A pregnancy test has 95% accuracy; however, it may come back as a false positive. Hegar sign is a softening of the uterine isthmus. Chadwick sign may have other causes besides pregnancy.
The nurse is assessing client status and behavior as the client attends monthly visits to the obstetrician. At which time during pregnancy does the nurse anticipate the client changing the verbiage about the fetus, from referring to an object to referring to a human pronoun?
in the second trimester as quickening occurs The nurse assesses the pregnant parent not only physically but psychosocially as well. The nurse watches for clues that the client is accepting the child. This most often occurs in the second trimester after quickening occurs. Quickening allows for the client to understand the child's presence and proof of existence. Typical confirmation of pregnancy occurs early with little outward changes occurring to the pregnant parent. Acceptance should occur prior to the imminent birth of the fetus, when the fetus is engaged and labor is anticipated. The family is told at varying times. Nesting occurs in the third trimester when preparation for the newborn occurs.
