Chapter 25: Pregnant Woman

While caring for a pregnant client at 8 weeks' gestation, the client asks the nurse, "When can you hear the baby's heartbeat?" The nurse should instruct the client that when a Doppler device is used, the earliest time when the fetal heart rate can be heard is the gestational age of

10 weeks Rationale: A fetal Doppler ultrasound device can be used after 10-12 weeks' gestation to hear the fetal heartbeat.

A nurse inspects a pregnant woman's cervix and notes it to be bluish in color. What is the correct term the nurse should use to document this finding?

Chadwick's sign Rationale: Normal changes of the cervix that occur during pregnancy are a bluish discoloration (Chadwick's sign) and softening (Goodell's sign). Cervical eversion is a normal finding of the cervix after a vaginal birth or when the woman takes birth control pills. The columnar epithelium from within the endocervical canal is everted and appears as a red, rough ring around the cervical os. A stellate laceration is a type of healed laceration that may be seen in a woman who has given birth vaginally.

A nurse assesses a primigravida client and observes darkening of the skin on the client's face. How should the nurse document this pigmentation?

Chloasma Rationale: The nurse should document the darkening of the skin on the client's face as chloasma, or the facial "mask of pregnancy." Linea nigra is a dark line extending from the umbilicus to the mons pubis. Spider nevi are tiny, red angiomas occurring on the face, neck, chest, arms, and legs, and may occur because of elevated estrogen levels. Palmar erythema is a pinkish color on the palms of the hands.

A client reports that her last menstrual period was on August 1. Using Naegele's rule, what would the nurse anticipate as the client's due date?

May 8 Rationale: The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP).

One cardiac change that commonly occurs in a pregnant client is

an increase in maternal blood volume by 40% to 50%. Rationale: One of the most dynamic changes is the increase in cardiac output and maternal blood volume by approximately 40% to 50%.

A client who is of normal weight just learned that she is 10 weeks pregnant. The client asks the nurse about weight gain during pregnancy. The nurse should instruct the client that the recommended weight gain is

25 to 35 pounds. Rationale: Optimal weight gain during pregnancy depends on the client's height and weight. Recommended weight gain in pregnancy is as follows: Underweight client, 28-40 lb; normal weight client, 25-35 lb; overweight client, 15-25 lb; twin gestation, 35-45 lb.

As part of a 31-year-old client's prenatal care, the nurse is assessing immunization history. Which of the following immunizations is most relevant to ensuring a healthy fetus?

Rubella Rationale: Maternal exposure to rubella during pregnancy poses a particular fetal risk that supersedes the significance of hepatitis, measles, diphtheria, tetanus, or pertussis.

A pregnant client visits the clinic for the first time. The client tells the nurse that this is her first pregnancy and that she and her husband are Ashkenazi Jews and immigrated to the United States from Israel. The nurse should encourage the client to be tested for

Tay-Sachs disease. Rationale: Certain inherited disorders occur more often in particular ethnic groups such as Tay-Sachs disease in the Ashkenazi Jewish population.

The blood tests for a primigravida client indicate that the client is Rh-negative and her partner is Rh-positive. What is an appropriate nursing intervention for this client?

Arrange for Rho immune globulin at 28 weeks' gestation Rationale: The nurse should inform the client that Rh-negative mothers should receive Rho immune globulin at 28 weeks' gestation and with antepartum testing to prevent isoimmunization. Positive antibody screens need to be followed up to identify antibodies detected in the blood to prevent fetal complications. The nurse need not make arrangements for blood transfusions, inform the client about the possibility of a cesarean section, or prepare the client for the possibility of a spontaneous abortion.

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?

Quickening Rationale: 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.

A client in her third trimester is scheduled for a nonstress test. What is the purpose of the nonstress test for the client?

To determine the well-being of the fetus Rationale: The purpose of the nonstress test is to determine fetal well-being. In this noninvasive test, the nurse will link the client to an electronic fetal monitor, place the tocodynamometer on the fundus to measure uterine contractions, and place the ultrasound monitor where the fetal heart can be heard to measure the fetal heart rate.

A woman has a positive pregnancy test and comes to the nurse with left lower quadrant pain. Bimanual examination reveals a tender mass. Which of the following is suspected?

Tubal pregnancy Rationale: Lower quadrant pain in a young woman could represent any of these possibilities. A positive HCG test and left, not right-sided, pain make appendicitis less likely. Presence of an extrauterine mass makes threatened abortion less likely.

A woman in her sixth month of pregnancy comes in for her first prenatal examination. She complains today of headache and abdominal pain of several months' duration. She appears somewhat hurried or nervous. What questions would the nurse ask next?

"Do you feel safe at home?" Rationale: All these questions are important when interviewing a pregnant woman. This picture may make you think of social problems such as domestic violence, substance abuse, or both. Asking more directed questions in these areas may be fruitful.

During the health interview of a client who has just learned that she is pregnant, the nurse is assessing the client's health history. What assessment question most directly addresses a known risk for congenital malformations?

"Do you have diabetes?" Rationale: Maternal diabetes is associated with an increased risk for congenital malformations. Sedentary lifestyle, premenstrual symptoms, and irregular menstrual periods do not carry this risk.

A nurse asks a 28-year-old client in their 6th week of gestation (G4, T3, P0, A1, L3), "Did you have a RhoGAM injection after your miscarriage? The client is unsure and asks the nurse to explain why RhoGAM would be given. What is the best response of the nurse?

"RhoGAM protects against an antibody reaction that may harm the fetus." Rationale: RhoGAM is administered to Rh-negative mothers who are carrying an Rh-positive fetus. Blood cells of the fetus may get into the mother's blood causing a production of antibodies, which in a subsequent pregnancy may cross the placenta and destroy red blood cells of an Rh-positive fetus. RhoGAM protects the mother from the Rh-positive blood cells to prevent the antigen/antibody reaction. RhoGAM is not administered to multiparas to prevent preterm labor. RhoGAM is not administered to prevent spontaneous abortions from occurring. RhoGAM should be given to Rh-negative women after miscarriage to protect the unborn fetus because the blood type of the miscarried fetus is unknown.

A client who is 32 weeks' gestation tells the nurse that she has been experiencing shortness of breath when walking up the steps at home. She is concerned that something is wrong. What is the nurse's best response?

"The enlarging uterus pushes against your diaphragm, and this makes breathing shallow." Rationale: Increasing levels of progesterone cause relaxation of ligaments and joints. This allows the rib cage to flare to accommodate the enlarging uterus. As the uterus enlarges, it pushes up against the diaphragm. This changes respirations from abdominal to costal, causing the woman to feel short of breath. The nurse should never demean a client's symptoms. Oxygen requirements do increase during pregnancy, but this is not the reason for the woman's shortness of breath.

The clinic nurse is assessing a client who is pregnant at 18 weeks' gestation. The nurse is obtaining a fetal heart rate using Doppler ultrasound. What fetal heart rate represents an expected finding?

130 beats per minute Rationale: Fetal heart rate ranges from 120 to 160 beats/min.

A pregnant client of normal weight is concerned about excessive weight gain during her pregnancy. She states, "I don't want to get fat!" The nurse should inform her that she can expect to gain how much weight during her pregnancy?

25 to 30 pounds Rationale: A simple rule of thumb for a woman of normal pre-pregnant weight is that she will gain about 10 pounds by 20 weeks and about 1 lb/week for the remaining 20 weeks, for a total of 25 to 30 pounds.

A pregnant woman should drink at least

2 L/day of water Rationale: Increased urination in pregnancy is common, as a result of the relaxation of the urinary system due to increased progesterone. This is one reason why it is important for the woman to drink 2 L/day of water.

The nurse is measuring the fundal height of a woman who is 28 weeks' gestation. Which measurement would the nurse expect?

28 cm Rationale: Fundal height should be approximately equal to the number of weeks' gestation. In this case, it would be 28 cm.

Mrs. Kelly comes to the clinic for her usual prenatal check-up. The nurse measures the fundal height at 24 cm. What is the estimated length of her gestation?

24 weeks Rationale: Fundal height is an approximation of the number of weeks of gestation. Between 20 to 32 weeks, SFH = gestation in weeks +2 cm.

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

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

What percent of miscarriages occur in the first trimester?

80% Rationale: Between 25% and 50% of conceptions do not result in a viable pregnancy. Eighty percent of miscarriages (spontaneous abortions) occur during the first trimester, and more than half of these miscarriages are the result of chromosomal abnormalities. Another 40% have abnormal development of the egg just after fertilization, sometimes characterized as a "blighted ovum" or "chemical pregnancy." Nearly all first-trimester miscarriages cannot be prevented, either by the mother or the clinician.

A woman who recently found out she was pregnant is asking what day her baby is due. The first day of her last menstrual period was July 12, 2014. When is she due according to Naegele's Rule?

April 19, 2015 Rationale: Due date may be estimated by using Naegele's Rule, which states that subtract 3 months from the first day of the LMP and add 7 days to the result. Thus, a woman whose LMP began July 12, 2014 would have an EDB of April 19, 2015.

The blood tests for a primigravida client indicate that the client is Rh-negative and her partner's blood type is unknown. What is an appropriate nursing intervention for this client?

Arrange for Rho immunoglobulin at 28 weeks' gestation Rationale: The nurse should inform the client that Rh-negative mothers should receive Rho immunoglobulin at 28 weeks' gestation and with antepartum testing to prevent isoimmunization if the partner's blood type is unknown. The nurse need not make arrangements for blood transfusions, inform the client about the possibility of a cesarean section, or prepare the client for the possibility of a spontaneous abortion.

A client at 32 weeks' gestation, who has had regular prenatal care, is found to have gained 6 pounds in 1 week. What would the nurse to do next?

Assess the legs for edema. Rationale: A sudden gain exceeding 5 pounds a week may be associated with pregnancy-induced hypertension and fluid retention. Therefore the nurse would assess the client's legs for edema. Assessing the client's diet may be appropriate if there are no other indications of problems occurring. A sudden weight gain is unrelated to a urinary tract infection, which would indicate the need for a urine culture. Checking fundal height is done regardless of the client's weight.

What anatomic area should be examined when assessing Montgomery tubercles?

Breasts Rationale: Montgomery tubercles are sebaceous glands on the areola of the breasts and are prominent during pregnancy.

The nurse is preparing to perform Leopold's maneuvers. During the first maneuver, the nurse palpates a soft mass in the upper quadrant of the abdomen. The nurse interprets this as which fetal part?

Buttocks Rationale: On the first maneuver, the soft mass palpated in the upper quadrant would most likely be the fetal buttocks. The head would feel round and hard. The back would be smooth, and the fetal fists and feet would feel nodular and are only noted with the second maneuver.

Increased pigmentation on the face of some pregnant women is called:

Chloasma Rationale: Chloasma, or "mask of pregnancy," is a blotchy brown discoloration on the face. In some women, a darkened line up the abdomen appears, which is called linea nigra. Striae are "stretch marks," while melanotropin is the hormone responsible for chloasma.

A client who is 37 years of age presents to the health care clinic for her first prenatal check up. Due to her advanced age, the nurse should prepare to talk with the client about her increased risk for what complication?

Genetic disorders Rationale: Women over the age of 35 are at increased risk of having a fetus with an abnormal karyotype or other genetic disorders. Gestational diabetes, an incompetent cervix, and preterm labor are risks for any pregnant woman.

A pregnant client tests positive for Group B Streptococcus. The nurse understands that what intervention is necessary to protect the infant?

Give the mother antibiotics 4 hours prior to delivery. Rationale: Protection of the infant results when antibiotics are administered 4 hours prior to delivery. Women who are positive for Group B are encouraged to notify their providers early in labor.

A nurse inspects a pregnant woman's cervix and notes that it has softened. What is the correct term the nurse should use to document this finding?

Goodell's sign Rationale: Normal changes of the cervix that occur during pregnancy are a bluish discoloration (Chadwick's sign) and softening (Goodell's sign). Cervical eversion is a normal finding of the cervix after a vaginal birth or when the woman takes birth control pills. The columnar epithelium from within the endocervical canal is everted and appears as a red, rough ring around the cervical os. A stellate laceration is a type of healed laceration that may be seen in a woman who has given birth vaginally.

A client who is at 23 weeks' gestation tells the nurse, "I just burn up all the time. I can't even sleep with any covers on me!" The nurse explains to the client that this is primarily due to which physiologic change?

Increased basal metabolic rate Rationale: The increased production of hormones, especially triiodothyronine and thyroxine, speeds the metabolic rate in a term pregnancy, contributing to heat intolerance. Sweat gland activity increases in pregnancy. Increased maternal blood volume increases the heart rate. Stretching of the abdominal muscles occurs due to uterine enlargement, possibly leading to permanent separation of the abdominal muscles.

Before beginning the initial prenatal examination, a nurse should instruct a client to complete what procedure before undressing?

Obtain a clean catch urine Rationale: The first procedure a nurse should ask the client to do is obtain a clean catch, midstream urine before undressing. Lab tests can be done after the examination is complete. At the first visit, the fetus is too small to be measured or ultrasound done.

A nurse assesses a primigravida client and observes a pinkish color on the palms of the hands. How should the nurse document this pigmentation?

Palmar erythema Rationale: Palmar erythema is a pinkish color on the palms of the hands that often occurs during pregnancy. The darkening of the skin on the face that occurs during pregnancy is chloasma, or the facial "mask of pregnancy." Linea nigra is a dark line extending from the umbilicus to the mons pubis. Spider nevi are tiny, red angiomas occurring on the face, neck, chest, arms, and legs, and may occur because of elevated estrogen levels.

A client at her prenatal visit is found to have 1+ protein in her urine. This is suggestive of what health problem?

Preeclampsia Rationale: Proteinuria 1+ or greater may indicate preeclampsia and thus requires a provider's attention.

A client who is at 32 weeks' gestation has developed a physiologic anemia. The nurse understands that which of the following is the cause of such anemia?

The increase in plasma volume being greater than the increase in red blood cells Rationale: With the dynamic increase in maternal blood volume, a physiologic anemia (pseudoanemia) commonly develops. This anemia results primarily from the disproportionate increase in blood volume compared to the increased red blood cell (RBC) production. Plasma volume increases 40% to 50% and RBC volume increases 18% to 30% by 30 to 34 weeks' gestation. There are no indications that the client's anemia is from internal bleeding, lack of iron in the diet, or leukemia.

A client at 32 weeks' gestation has been placed on complete bed rest due to premature labor contractions. The nurse should prioritize assessments for which complication?

Thrombophlebitis Rationale: Pregnant women are more prone to the development of thrombophlebitis because of the hypercoagulable state of pregnancy. Women placed on bed rest during pregnancy are at a very high risk for thrombophlebitis. Hyperglycemia, urinary tract infection, or leg cramps are normally unrelated to bed rest.

A pregnant client at 12 weeks' gestation visits the clinic and tells the nurse that she has been vomiting severely for the past 5 days. The nurse should refer the client to a physician for possible

hyperemesis gravidarum Rationale: If proper hydration and nutrition are not maintained, the client may be at risk for hyperemesis gravidarum.

The pregnant client tells the nurse she has a history of mitral valve stenosis. The nurse plans to closely monitor the client based on the understanding that which physiologic change in pregnancy increases this client's risk for complications?

increased blood volume Rationale: The increase in cardiac output and maternal blood volume places a client with mitral valve disease at increased risk for complications because of the extra demand placed on the heart. Physiologic anemia is the result of the increased blood volume. Altered carbohydrate metabolism might be problematic for the client with diabetes. Hormonal changes would not play a role in increasing the woman's risk for complications in this situation.

While assessing a pregnant client at 36 weeks' gestation, the nurse observes that the client's face is edematous and she has 3+ reflexes with mild clonus. The nurse should refer the client to a physician for possible

pregnancy-induced hypertension Rationale: After 20 weeks, increased BP (greater than 140/90) may be associated with pregnancy-induced hypertension.

The nurse is measuring a pregnant client's fundal height during a scheduled prenatal visit. The nurse should measure with reference to what anatomical landmarks?

the symphysis pubis and the fundus Rationale: Fundal height is measured between the symphysis pubis and the fundus. The edge of the fundus and umbilicus, the fundus and the abdomen, and the xiphoid process and the symphysis pubis, are not anatomical landmarks that are used to measure a pregnant client's fundal height.

A client who is being seen at her 14-week gestation visit reports having increased nasal congestion and occasional nose bleeds. How should the nurse respond?

"These symptoms are common during pregnancy due to increased estrogen levels." Rationale: Nasal "stuffiness" and nose bleeds (epistaxis) are common during pregnancy due to estrogen-induced edema and vascular congestion of the nasal mucosa and sinuses. The nurse could perform a focused assessment and obtain blood work, but it is not required because these are common occurrences during pregnancy. During pregnancy hematocrit increases, making the blood thicker not thinner.

A client at 24 weeks' gestation with hyperpigmentation asks the nurse, "What do you recommend I do about my skin changes?" How should the nurse respond?

"This is an expected skin change during pregnancy." Rationale: The nurse should respond with the statement, "This is an expected skin change during pregnancy," because hyperpigmentation might occur due to expected hormonal changes during pregnancy. Breast shields can be inserted into the bra for nipple inversion. Bloody discharge from the nipple and retraction of the skin could indicate breast cancer. Edema of the face may indicate the presence of pregnancy-induced hypertension.

During an assessment the nurse notes that a pregnant client has nasal mucosal swelling, redness, and occasional epistaxis. What should the nurse consider is causing these symptoms?

Increased estrogen production Rationale: Nasal mucosal swelling, redness, and epistaxis occurs because of increased estrogen production and increased vascular supply to the nares during pregnancy. This client's symptoms are not associated with excessive exercise, a vitamin deficiency, or insufficient dairy intake.

A 29-year-old homemaker who is G4P3 comes to the clinic for her first prenatal examination. Her last menstrual period was 2 months ago. She has had three previous pregnancies and births with no complications. She has no medical problems and has had no surgeries. Her only current complaint is severe reflux in the mornings and evenings. Examination reveals no acute distress. Her blood pressure is 110/70 with a pulse of 88. Her respirations are 16. Head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On bimanual examination, her cervix is soft and her uterus is 10 weeks in size. Pap smear, cultures, and blood work are pending.

Increasing progesterone level Rationale: Progesterone lowers esophageal sphincter tone, leading to reflux and heartburn. It also relaxes tone and contraction of the ureters and bladder, increasing risk of UTI and subsequent bacteremia.

A nurse is educating a 16-year-old client who is 10 weeks pregnant about nutrition and healthy weight gain during pregnancy. What should the nurse include in the teaching?

Insufficient weight gain during pregnancy may result in low birth weight. Rationale: Insufficient weight gain during pregnancy may result in intrauterine growth retardation and low birth weight. All women do not need to gain a minimum of 20 lbs during pregnancy; pregnancy weight gain is based on pre-pregnancy weight. Underweight women need to gain more weight than overweight women. It does matter how much weight is gained during pregnancy. Too much weight gain during pregnancy does not necessarily lead to gestational diabetes or a large-for-gestational-age baby. Some women are predisposed to developing gestational diabetes no matter how much weight they gain during pregnancy.

A client in her third trimester of pregnancy is undergoing a physical assessment. Her nurse explains that she is about to estimate what position the fetus is presently in by palpating the uterine fundus to see whether the head or buttocks is presenting. What is this procedure called?

Leopold's maneuver Rationale: Leopold's maneuvers are performed to determine the position of the fetus and determine whether the fundus contains the head or the buttocks. The head moves independently of the torso but the buttocks do not.

The nurse is assessing a pregnant client and is performing Leopold maneuvers. For the first two maneuvers, the nurse will perform which action?

Palpate the client's fundal region and then the lateral sides of the abdomen. Rationale: For the first maneuver, the nurse faces the client's head and places the hands on the fundal area. For the second maneuver, the hands are moved to the lateral sides of the abdomen. Palpating the area just above the symphysis pubis and grasping the presenting part with the thumb and third finger are both part of the third Leopold maneuver. The fourth Leopold maneuver involves the nurse placing the hands on the client's abdomen and trying to move the hands toward each other while applying downward pressure.

A client who is pregnant presents to the health care clinic for a routine checkup. She tells the nurse that her hands have been tingling over the past 2 weeks and they often become numb at night. What assessment should the nurse perform to obtain data in regards to this subjective information?

Perform the Phalen's test Rationale: The client's symptoms are suggestive of carpal tunnel syndrome, a common occurrence in pregnancy due to retention of fluid that causes swelling and compression of the median nerve. Phalen's test is used to confirm this condition. Range of motion tests joint mobility. Palpation of the anatomic snuffbox is done if there is a suspected fracture of the scaphoid. Heberden's nodes are seen in osteoarthritis.

In assessing a client who is in her second trimester, a nurse observes that the client is underweight and anemic from lack of dietary iron. The nurse suspects malnutrition and asks the client about her diet and eating habits. The client confesses that she has been craving and eating clay recently. The nurse recognizes this condition as which of the following?

Pica Rationale: Pica, a craving for or ingestion of nonnutritional substances such as dirt or clay, is seen in all socioeconomic classes and cultures. Pica can be a major concern if the craving interferes with proper nutrition during pregnancy. Ptyalism, excessive salivation, may occur in the first trimester. Chloasma is a darkening of the skin on the face, known as the facial "mask of pregnancy." Polyhydramnios is an excess of amniotic fluid in the uterus.

A client who is in her 34th week of gestation complains of continual vaginal bleeding that started suddenly a few days ago. Which of the following conditions should the nurse most suspect in this situation?

Placenta previa Rationale: Vaginal bleeding may indicate placenta previa. Leakage of fluid may indicate membrane rupture. Vaginal discharge may indicate vaginal infections (e.g., bacterial vaginosis, trichomoniasis, gonorrhea, chlamydia). Untreated infections can predispose the client to preterm labor or fetal infections.

The client has confirmation of an unruptured ectopic pregnancy. What does the nurse anticipate will be a priority intervention?

Prepare the client for termination of the pregnancy. Rationale: Ectopic pregnancy is a pregnancy outside of the uterus, usually because the egg does not leave the fallopian tube. Confirmation of ectopic pregnancy is considered an obstetric emergency requiring hospitalization and termination of the pregnancy.

A nurse assesses a 23-year-old primigravida client in her first trimester. The client reports problems with excessive salivation. Which of the following conditions should the nurse document in this client?

Ptyalism Rationale: Ptyalism, or excessive salivation, may occur in the first trimester. Constipation is a common problem during pregnancy, especially in clients who take iron supplements, and hemorrhoids may develop because of the pressure on the venous structures from straining to have a bowel movement. Gastric ulcers may cause bleeding and would be a reason for taking iron supplements. Pica, a craving for or ingestion of nonnutritional substances such as dirt or clay, is seen in all socioeconomic classes and cultures. Pica can be a major concern if the craving interferes with proper nutrition during pregnancy.

A client is 28 weeks pregnant when lab work is completed in the clinic. The client is Rh negative with a white blood cell count of 12,000 and normal platelet count. The nurse should plan for which treatment?

RhoGAM administration Rationale: Mothers with Rh negative blood are given RhoGAM at approximately 28 weeks' gestation or in cases of abdominal trauma or miscarriage. This is to prevent isoimmunization of the mother, which can endanger future pregnancies. Anemia may be treated with iron supplementation or iron-rich foods. Thalassemias may require referral to specialists because the condition poses some risks to the fetus. Patients with low-platelet levels are at risk for hemorrhage or disseminated intravascular coagulation and may not be candidates for epidurals. White blood cell (WBC) counts are usually elevated in pregnancy; they may be as high as 12,000/mm3 prenatally, and during labor they may rise as high as 30,000/mm3. WBCs in excess of these numbers suggest a potential infection.

What cervical change should a nurse recognize as indicating that a woman has delivered a fetus vaginally?

Slit-like appearance Rationale: A slit-like appearance to the cervix is seen in women with a previous vaginal delivery. The trauma of a vaginal birth may produce a tear or laceration. When the laceration heals it leaves a slit-like appearance to the cervix. A small amount of whitish discharge, called leukorrhea, is normal. Chadwick's sign is a bluish discoloration of the cervix seen in pregnancy. Nabothian cysts are retention cysts on the surface of the cervix that are normal in women after childbirth.

In examining a client who is in her third trimester, the nurse notes pinkish-red streaks with slight depressions in the skin over the client's abdomen and breasts. The nurse documents this finding as which of the following?

Striae gravidarum Rationale: The nurse should document the appearance of pinkish-red streaks with slight depressions as striae gravidarum, or stretch marks. Darkening of the skin on the client's face is chloasma, or the facial "mask of pregnancy." Linea nigra is a dark line extending from the umbilicus to the mons pubis. Spider nevi are tiny red angiomas occurring on the face, neck, chest, arms, and legs, and may occur because of elevated estrogen levels. Palmar erythema is a pinkish color on the palms of the hands.

A pregnant client in her first trimester states, "I think I must be having a miscarriage. I have sharp pains in my lower abdomen sometimes!" What does the nurse understand is happening to this client?

The client is experiencing stretching of the round and broad ligaments. Rationale: In the first trimester of pregnancy, sharp pains in the lower abdomen are common. Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short and have a stabbing quality. They are not repetitive, but are often associated with position changes, or later fetal movements.

At what point in the pregnancy is it possible for the fetus to survive outside the womb?

The end of the second trimester Rationale: During the second trimester, fetal growth is significant. The fetus begins this trimester 3 inches long and weighing less than 1 oz (0.8 gm). By the end of the second trimester, the fetus is about 15 inches long and weighs more than 2 lbs (1000 gm). Major organs develop to the point that the fetus may survive with help outside the womb.

A woman is only 30 weeks pregnant, but the physician determines that the fetus must be delivered for the safety of the mother. The physician orders a glucocorticosteroid injection to be given. Why does the physician order this injection?

To promote the formation of surfactant in the fetal lungs Rationale: A key task of the third trimester is maturation of the fetal lungs. Growth factors in amniotic fluid promote growth and differentiation of lung tissue. With normal amniotic fluid volume, functionality of the lungs depends on their ability to form surfactant, which prevents collapse of the alveoli upon expiration. If a fetus must be delivered between 28 and 34 weeks, a glucocorticosteroid injection is given to the mother to promote the formation of surfactant.

A nurse assesses a primigravida client and observes a dark line extending from the umbilicus to the mons pubis. How should the nurse document this pigmentation?

Linea nigra Rationale: Linea nigra is a dark line extending from the umbilicus to the mons pubis. Darkening of the skin on the face during pregnancy is chloasma, or the facial "mask of pregnancy." Spider nevi are tiny, red angiomas occurring on the face, neck, chest, arms, and legs, and may occur because of elevated estrogen levels. Palmar erythema is a pinkish color on the palms of the hands that often occurs in pregnancy.

A pregnant client states, "I am only 6 weeks pregnant, but the morning sickness is awful. When is it going to stop?" What is the best response by the nurse?

"Usually after 12 weeks, when the placenta starts managing the production of progesterone, morning sickness ends." Rationale: By 12 weeks' gestation, the placenta has grown sufficiently to take over production of progesterone and the corpus luteum is absorbed. Most women who have morning sickness start feeling better once the placenta takes over.

A nurse is assessing a client with type 1 diabetes who is 20 weeks' pregnant. Which assessment finding(s) would cause concern for the nurse? Select all that apply.

> congenital malformations > elevated hemoglobin A1C levels > increased blood pressure > protein in the urine Rationale: An elevated hemoglobin A1C level indicates poor control of glucose levels. Hypertension and protein in the urine are signs of preeclampsia, pregnancy-induced hypertension that can cause preterm labor. The fundal height at the umbilicus is normal for 20 weeks. A 12-lb weight gain is normal at 20 weeks' gestation. Women should gain between 2 and 4 lbs their first trimester and 11 to 12 lbs in both their second and third trimester for a total of 25 lbs for the entire pregnancy.