Exam 1 extras
A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate? "Breast-feeding can start 6 months after delivery." "Breast-feeding is allowed after the baby has been vaccinated with immune globulin." "Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby." "Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery."
"Breast-feeding is allowed after the baby has been vaccinated with immune globulin." Although HBV is transmitted in breast milk, after scheduled newborn vaccines and immune globulin have been administered to the newborn, the woman may breast-feed without risk to the newborn. The remaining options are incorrect responses.
A 39-week-gestation pregnant client calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse? "Six to eight fetal movements in a 24-hour period are adequate to determine that the fetus is healthy." "Fetal movement is a sign of fetal health. Even if the amount has decreased, the fetus is still healthy." "Continue to count fetal movements for the next 24 hours and call your primary health care provider if the number of movements continues to decrease." "Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your primary health care provider for further evaluation."
"Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your primary health care provider for further evaluation." Fetal movements may decrease during fetal sleep cycles and while a woman is taking depressant medication, drinking alcohol, or smoking cigarettes. A decrease in fetal movement over a period of 1 or more days or as a woman approaches term is abnormal and requires further evaluation for fetal well-being. In most protocols for fetal movement, 10 movements in any designated amount of time (usually 2 or 3 hours) is the minimal number required to determine fetal health, so option 1 can be eliminated because it does not meet the minimal fetal movement requirement. Although fetal movement is a reassuring sign of fetal health, fetal movement that is perceived as being less than on the previous day could indicate a decrease in fetal oxygenation and a need for further evaluation, so therefore eliminate option 2. Option 3 can be eliminated because this recommendation would delay time that could be used to diagnose a possible at-risk fetus.
The nurse is providing instructions regarding the treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? "I should avoid straining during bowel movements." "I can gently replace the hemorrhoids into the rectum." "I can apply ice packs to the hemorrhoids to reduce the swelling." "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."
"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the discomfort from hemorrhoids.
The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? "I do not need to abstain from sexual intercourse." "I need to use vaginal creams after I douche every day." "I need to douche and perform a sitz bath 3 times a day." "It may be necessary to have a cesarean section for delivery."
"It may be necessary to have a cesarean section for delivery." If a woman has an active lesion, either recurrent or primary at the time of labor, delivery should be by cesarean section. Women are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the woman should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area should be kept clean and dry to promote healing.
A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman? "You should avoid all school-age children during pregnancy." "There is no need to be concerned if you don't have a fever or rash within the next 2 days." "Be sure to tell the primary health care provider on your next prenatal visit, but there is little risk in the second trimester." "You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed."
"You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed." Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks associated with maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies. Rubella titer determination is a standard antenatal test for childbearing women during their initial screening and entry into the health care delivery system. The correct option helps to clarify maternal concerns with accurate information based on the acquisition of rubella infection and potential fetal side effects.
A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? "You will be isolated from your newborn infant after delivery." "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."
"You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed." With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery.
The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? "Most children do not receive the vaccine until they are 5 years of age." "You are still susceptible to rubella, so your toddler should receive the vaccine." "It is not advised for children of pregnant women to be vaccinated during their mother's pregnancy." "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."
"Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." All pregnant women should be screened for prior rubella exposure during pregnancy. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to rubella. All children of pregnant women should receive their immunizations according to schedule. In addition, no definitive evidence suggests that the rubella vaccine virus is transmitted from client to client.
The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period? A 35-year-old client who reports that she smokes A 26-year-old client with a family history of thrombophlebitis A 37-year-old client in her fourth pregnancy who is overweight A 22-year-old client in her first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis
A 26-year-old client with a family history of thrombophlebitis Certain factors create a risk for the development of thrombophlebitis. These factors include smoking, varicose veins, obesity, a history of thrombophlebitis, women who are older than 35 years or have had more than 3 pregnancies, and women who have had a cesarean birth. The client described in the correct option is least likely to be at risk for the development of a thromboembolic disorder because this client has a family history rather than a personal history of thrombophlebitis.
The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client? Sexual intercourse is acceptable up until 30 weeks. Antiviral medications need to be taken during the entire pregnancy. A vaginal delivery is allowed even if vaginal lesions are present at the time of labor. A cesarean section will be necessary if vaginal lesions are present and active at the time of labor.
A cesarean section will be necessary if vaginal lesions are present and active at the time of labor. For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. The safety of antiviral medications has not been established during pregnancy, and it should be used only when a life-threatening infection is present.
The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? Increased urinary output A fetal heart rate of 90 beats/minute 3 contractions occurring within a 10-minute period Adequate resting tone of the uterus palpated between contractions
A fetal heart rate of 90 beats/minute A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress.
Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? Continue the oxytocin drip. Slow the intravenous (IV) rate. Place the client in a high-Fowler's position. Administer oxygen at 8 to 10 L/min via face mask.
Administer oxygen at 8 to 10 L/min via face mask. Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The IV infusion should be increased, not decreased, so as to increase the maternal blood volume. The woman's position should be lateral with legs raised to increase maternal blood volume and improve the maternal vascular system.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? Administer oxygen via face mask. Place the mother in a supine position. Increase the rate of the oxytocin intravenous infusion. Document the findings and continue to monitor the fetal patterns.
Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? Slow the intravenous flow rate. Continue the oxytocin drip if infusing. Place the client in a high-Fowler's position. Administer oxygen, 8 to 10 L/minute, via face mask.
Administer oxygen, 8 to 10 L/minute, via face mask. Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per primary health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion.
The nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding, the nurse should prepare for which appropriate nursing action? Administering oxygen via face mask Placing the mother in a supine position Increasing the rate of the intravenous (IV) oxytocin infusion Documenting the findings and continuing to monitor the fetal patterns
Administering oxygen via face mask Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned on her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Documenting and monitoring would delay necessary treatment.
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. Bed rest as a necessary preventive measure may be prescribed. Administration of subcutaneous heparin postdelivery as prescribed. An overbed lift may be necessary if the client requires a cesarean section. Less frequent cleansing of a cesarean incision, if present, may be prescribed. Thromboembolism stockings or sequential compression devices may be prescribed.
Administration of subcutaneous heparin postdelivery as prescribed. An overbed lift may be necessary if the client requires a cesarean section. Thromboembolism stockings or sequential compression devices may be prescribed. The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.
After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? Reposition the laboring woman to knee-chest. Assess the vagina and cervix with a gloved hand. Notify the primary health care provider of the need for an amnioinfusion. Document the description of the fetal bradycardia in the nursing notes.
Assess the vagina and cervix with a gloved hand. It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.
he nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Uterine rigidity Uterine tenderness Severe abdominal pain Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age
Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Uterine rigidity Uterine tenderness Severe abdominal pain Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age
Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation, as the blood penetrates the myometrium and causes uterine irritability.
A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? Provide the client with instructions on how to push. Prepare the labor room and the client for an imminent delivery. Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). Call the PHCP to the labor and delivery unit to perform a delivery.
Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). The client evidences progression toward delivery because the cervix is dilated 6 cm and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, her neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that IAP be administered during labor. Providing the client with instructions on pushing is not appropriate at a time when she does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore, the PHCP is not required for delivery at this time.
The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? Chest pain A rigid abdomen A soft and boggy uterus Complaints of severe abdominal pain
Complaints of severe abdominal pain Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting.
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? Document the finding. Encourage the client to ambulate. Encourage the client to increase fluid intake. Contact the obstetrician (OB) and inform him or her of this finding.
Contact the obstetrician (OB) and inform him or her of this finding. Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized.
The nurse is preparing to care for a client in labor. The primary health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? An IV infusion of antibiotics Placing the client on complete bed rest Continuous electronic fetal monitoring Placing a code cart at the client's bedside
Continuous electronic fetal monitoring Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? Notify the primary health care provider. Discontinue the infusion of oxytocin. Place oxygen on at 8 to 10 L/minute via face mask. Contact the client's primary support person(s) if not currently present.
Discontinue the infusion of oxytocin. The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.
The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? Prepare the client for a cesarean delivery. Monitor the FHR every 30 minutes. Encourage an upright or side-lying maternal position. Increase the rate of the oxytocin infusion every 10 minutes.
Encourage an upright or side-lying maternal position. Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations, without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.
A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? Perform an abdominal scrub on the client. Prepare the delivery room for a vaginal delivery. Explain to the client why a cesarean delivery is necessary. Call the primary health care provider to obtain a prescription for an antiviral medication.
Explain to the client why a cesarean delivery is necessary. Because neonatal infection of HSV is life-threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal scrub will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms, not to eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? Hemoglobin of 11 g/dL (110 mmol/L) Fetal heart rate of 180 beats per minute Maternal pulse rate of 85 beats per minute White blood cell count of 12,000/mm3 (12 × 109/L)
Fetal heart rate of 180 beats per minute A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of, 11,000-15,000/mm3 (11-15 × 109/L) up to 18,000/mm3 (18 × 109/L) During the immediate postpartum period, the white blood cell count may be 25,000-30,000/mm3 (25-30 × 109/L) because of increased leukocytosis that occurs during delivery.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? Hemoglobin of 11 g/dL (110 mmol/L) Fetal heart rate of 180 beats/minute Maternal pulse rate of 85 beats/minute White blood cell count of 12,000 mm3 (12.0 × 109/L)
Fetal heart rate of 180 beats/minute A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 mm3 (11 to 15 x 10 9/L), up to 18,000 mm3 (18 x 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 x 109/L) because of increased leukocytosis that occurs during delivery.
The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply. Quickening Braxton Hicks contractions Fetal heart rate of 180 beats/minute Consistent increase in fundal height Elevated level of maternal serum alpha-fetoprotein (MSAFP)
Fetal heart rate of 180 beats/minute Elevated level of maternal serum alpha-fetoprotein (MSAFP) The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. An elevated MSAFP should be followed up with more specialized testing to determine if a neural tube problem exists. The remaining options are normal expected findings.
Which assessment finding after an amniotomy should be conducted first? Cervical dilation Bladder distention Fetal heart rate pattern Maternal blood pressure
Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.
The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? Forceps delivery Schultz presentation Hypotonic contractions Weak bearing-down efforts
Forceps delivery Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.
A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? The woman has the herpes simplex virus (HSV). The woman has contracted an airborne viral disease. The neonate will definitely develop this disease after birth. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.
HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test. Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA. HIV and herpes simplex virus are different types of infections. HIV infection occurs primarily through the exchange of body fluids, not via airborne disease. A neonate born to an HIV-positive mother is at risk for developing the virus, but it is not an absolute.
The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement should the nurse make to the client? Visitors are not allowed to hold the baby. There is no danger of the newborn contracting the disease. Hands should be washed thoroughly before holding the infant. The newborn infant will not be allowed in the mother's room at all.
Hands should be washed thoroughly before holding the infant. Transmission of infectious diseases can occur through contaminated items such as the hands and bed linens of clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is 1 of the most effective methods of preventing the transmission of infectious diseases. The newborn infant is allowed in the mother's room and visitors are allowed to hold the newborn infant as long as hand washing and other protective measures are instituted.
A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction? I should drink unpasteurized milk only.""I should cook meat thoroughly." "I should drink unpasteurized milk only." "I should avoid contact with materials that are possibly contaminated with cat feces." "I should avoid touching mucous membranes of the mouth or eyes while handling raw meat."
I should drink unpasteurized milk only." All pregnant women should be advised to follow certain procedures to prevent the development of toxoplasmosis. All meats should be cooked thoroughly. Pregnant clients should avoid uncooked eggs and unpasteurized milk. All fruits and vegetables should be washed before consumption. Contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sand boxes, or garden soil should be avoided. Last, the pregnant client should avoid touching mucous membranes of the mouth or eyes while handling raw meat, thoroughly wash all kitchen surfaces that come in contact with uncooked meat, and wash the hands thoroughly after handling raw meat.
A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? "I can douche anytime I want." "I can wear my tight-fitting jeans." "I should avoid the use of condoms." "I should wear underwear with a cotton panel liner."
I should wear underwear with a cotton panel liner." Wearing items with a cotton panel liner allows for air movement in and around the genital area. Douching is to be avoided. Wearing tight clothing can irritate the genital area and does not allow for air circulation. Condoms should be used to minimize the spread of genital tract infections.
A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. Back pain Heavy vaginal bleeding Increase in fundal height Hard, board-like abdomen Persistent abdominal pain Early deceleration on the fetal heart monitor
Increase in fundal height Hard, board-like abdomen Persistent abdominal pain The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; hard, board-like abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding.
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? Therapeutic abortion is required. Isoniazid plus rifampin will be required for 9 months. She will have to stay at home until treatment is completed. Medication will not be started until after delivery of the fetus.
Isoniazid plus rifampin will be required for 9 months. More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.
During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? Maternal infection Gestational hypertension Gestational diabetes mellitus Consumption of recent high-sugar snack
Maternal infection The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to approximately 110 to 160 beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes, and consuming a high-sugar diet may affect the fetal heart rate but are not the most likely causes.
A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? Measure fundal height. Attach electronic fetal monitoring. Prepare the client for a possible cesarean section. Visually examine the perineum and vaginal opening.
Measure fundal height. Measuring fundal height is least appropriate because it should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the primary health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.
The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? No accelerations of fetal heart rate (FHR) Moderate variability present Variable decelerations present FHR of 170 to 180 beats/minute
Moderate variability present Reassuring signs in the fetal heart tracing include an FHR of 110 to 160 beats/minute, accelerations of the FHR, no variable decelerations, and the presence of moderate variability. The moderate variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations indicate cord compression.
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? Record the findings. Massage the fundus. Notify the obstetrician (OB). Place the client in Trendelenburg's position.
Notify the obstetrician (OB). If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the OB.
A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? Immunization with rubella Retesting rubella titer during pregnancy Antibiotics to be taken throughout the pregnancy Counseling the mother regarding therapeutic abortion
Retesting rubella titer during pregnancy A rubella titer is performed to determine immunity to rubella. If the client's titer is less than 1:8, the mother is not immune. A retest during pregnancy is prescribed, and the mother is immunized postpartum if she is not immune. Antibiotics are not prescribed. Counseling the client regarding therapeutic abortion is an inaccurate option.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? Document the finding. Check the mother's heart rate. Notify the obstetrician (OB). Tell the client that the fetal heart rate is normal.
Notify the obstetrician (OB). The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the OB. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? Notify the primary health care provider (PHCP). Continue monitoring the fetal heart rate. Encourage the client to continue pushing with each contraction. Instruct the client's coach to continue to encourage breathing techniques.
Notify the primary health care provider (PHCP). A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? Notify the primary health care provider (PHCP). Continue monitoring the fetal heart rate. Encourage the client to continue pushing with each contraction. Instruct the client's coach to continue to encourage breathing techniques.
Notify the primary health care provider (PHCP). A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? Document the finding. Check the mother's heart rate. Tell the client that the fetal heart rate is normal. Notify the primary health care provider (PHCP).
Notify the primary health care provider (PHCP). The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the PHCP. Options 2 and 3 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the PHCP needs to be notified.
A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate? Document the findings. Notify the primary health care provider (PHCP). Inform the client that everything is normal and fine. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.
Notify the primary health care provider (PHCP). The fetal heart rate should be 110 to 160 beats/minute during pregnancy. A fetal heart rate of 90 beats/minute (bradycardia) requires that the PHCP be notified and the client be evaluated further. The other options are inappropriate and delay necessary intervention.
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? Prepare the client for an ultrasound. Obtain equipment for a manual pelvic examination. Prepare to draw a hemoglobin and hematocrit blood sample. Obtain equipment for external electronic fetal heart rate monitoring.
Obtain equipment for a manual pelvic examination. Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.
A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? Costovertebral angle pain Pain, itching, and vaginal discharge Absence of any signs and symptoms Proteinuria, hematuria, edema, and hypertension
Pain, itching, and vaginal discharge Clinical manifestations of a vaginal Candida infection include pain; itching; and a thick, white vaginal discharge. Costovertebral angle pain, proteinuria, hematuria, edema, and hypertension are clinical manifestations that may be associated with a urinary tract infection.
A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? Back pain Abdominal pain Painful vaginal bleeding Painless vaginal bleeding
Painless vaginal bleeding The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of abruptio placentae.
The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply. A tender and rigid uterus Painless, bright red vaginal bleeding Location in the lower uterine segment Greenish discoloration of the amniotic fluid Vaginal bleeding accompanied by abdominal pain
Painless, bright red vaginal bleeding Location in the lower uterine segment Placenta previa is a condition in which the placenta is located in the lower uterine segment. It does not cause pain but does cause bright red vaginal bleeding. This occurs because the placenta is overriding the cervical os, and as the cervix dilates the placental vessels bleed. Abruptio placenta is painful and results in a rigid and tender uterus. Greenish discoloration of the amniotic fluid occurs as a result of meconium staining.
On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? Episodic, late decelerations that indicate uteroplacental insufficiency Periodic, early decelerations that indicate fetal head compression Periodic, variable decelerations that indicate cord compression Episodic, early decelerations that may be a result of maternal hypotension
Periodic, early decelerations that indicate fetal head compression An early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described; therefore, eliminate option 3. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4.
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history? Hypotension Hypothyroidism Diabetes mellitus Peripheral vascular disease
Peripheral vascular disease Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? Maternal fatigue Coordinated uterine contractions Progressive changes in the cervix Persistent nonreassuring fetal heart rate
Persistent nonreassuring fetal heart rate Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.
The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk? Presence of cats in the home Number of sexual partners during pregnancy Exposure to children with rashes or gastrointestinal symptoms History of high fevers or unusual rashes during the first 6 weeks of pregnancy
Presence of cats in the home Toxoplasmosis is a systemic (and usually asymptomatic) illness caused by a protozoan parasite. Approximately one third of all women in the United States have positive antibody titers for toxoplasmosis, thus confirming prior exposure. Humans acquire the infection by consuming inadequately cooked meat, eggs, or milk; by ingesting or inhaling the oocyst stage excreted in feline feces or contaminated soil; or by receiving contaminated blood products. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection in the developing embryo or fetus. The other options are questions unrelated to toxoplasmosis.
he nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? Encourage early ambulation. Discuss the resumption of home care and other activities with the client. Review hand-washing techniques and pericare procedures with the client. Instruct the client in proper positioning of the newborn to facilitate breast-feeding.
Review hand-washing techniques and pericare procedures with the client. Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand-washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication.
The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? Stop the oxytocin infusion. Check the client's blood pressure. Check the client for bladder distention. Place the client in a side-lying position.
Stop the oxytocin infusion. Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The primary health care provider is notified. The nurse should monitor the client's blood pressure and intake and output; however, the nurse should first stop the infusion.
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. Early labor Amniotomy Tachycardia Fetal hypoxia Metabolic acidemia Congenital anomalies
Tachycardia Fetal hypoxia Metabolic acidemia Congenital anomalies The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into 4 different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. The client has a history of intravenous drug use. The client has a significant other who is heterosexual. The client has a history of sexually transmitted infections. The client has had one sexual partner for the past 10 years. The client has a previous history of gestational diabetes mellitus.
The client has a history of intravenous drug use. The client has a history of sexually transmitted infections. HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.
A pregnant client is diagnosed with tuberculosis. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis? Medication is not needed until after delivery. Tuberculosis is nothing to be concerned about. Tuberculosis cannot be transferred to the fetus. The newborn will be tested at birth and may be started on preventive therapy.
The newborn will be tested at birth and may be started on preventive therapy. More than 1 medication may be used to prevent the growth of resistant organisms in the pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for a total of 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing on the infant should be repeated at 3 months, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid should be given. Therefore, options 1, 2, and 3 are incorrect.
The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? Maternal fatigue The passage of meconium Coordinated uterine contractions Progressive changes in the cervix
The passage of meconium Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate; fetal acidosis; and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.
The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the primary health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? "This is necessary to relieve your anxiety." "This is necessary to eliminate the need for further uncomfortable screenings." "This is necessary to minimize the financial cost of caring for an HIV-positive client." "This is necessary to assist in identifying potential infections that may need to be treated."
This is necessary to assist in identifying potential infections that may need to be treated." The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include, for example, Candida infections, genital herpes, and anogenital condyloma. Early reporting of signs and symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being.
The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate. Which is the initial nursing action? Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.
Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned onto her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is then applied to the mother.
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. Fatigue Drowsiness Uterine hyperstimulation Late decelerations of the fetal heart rate Early decelerations of the fetal heart rate
Uterine hyperstimulation Late decelerations of the fetal heart rate Oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some obstetricians prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? Variability Accelerations Early decelerations Variable decelerations
Variable decelerations Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.
