Exam 3 Enhancement

A nurse in a provider's office is caring for a client who is at 36 weeks gestation and scheduled for an amniocentesis. The client ask why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? -"This will determine if there is more than one fetus." -"It is useful for estimating fetal age." -"It assists in identifying the location of the placenta and fetus." -"This is a screening tool for spina bifida."

"It assists in identifying the location of the placenta and fetus." Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.

A nurse is teaching a group of clients who are in their 1st trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? -"Refrain from exercises that include stretching." -"Moderate exercise improves circulation." -"It is recommended to increase your weight-bearing exercises." -"It is recommended to rest for 30 minutes before each new exercise."

"Moderate exercise improves circulation." Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone.

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? "Mongolian spots can be found on the skin of many newborns." "A caput succedaneum occurs due to compression of blood vessels." "This is a cephalhematoma, which can occur spontaneously." "This is erythema toxicum, which is a transient condition."

-"A caput succedaneum occurs due to compression of blood vessels." A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days.

A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? -"Ambivalent feelings are quite common for women early in pregnancy." -"Perhaps you should see a counselor to discuss these feelings further." -"Have you spoken to your mother about these feelings?" -"Don't worry. You will be fine once the baby is born."

-"Ambivalent feelings are quite common for women early in pregnancy." This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy.

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make? -"You are so young. Are you ready for the responsibilities of a sexual relationship?" -"Because of your age, I think that a barrier method would be the best choice." -"Before I can help you, I need to know more about your sexual activity." -"A provider can help you with that after a physical examination."

-"Before I can help you, I need to know more about your sexual activity." This is an example of providing a general lead when using therapeutic communication. It allows the client to provide information that will enhance effective consultation about the best form of contraception for her.

A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching? -"Black cohosh should not be taken during pregnancy." -"Black cohosh helps relieve headache pain." -"Black cohosh increases the risk for bleeding." -"Black cohosh is a stimulant."

-"Black cohosh should not be taken during pregnancy." Black cohosh has estrogenic properties and should not be taken during pregnancy.

A nurse is caring for a client who is in her 1st trimester of pregnancy and ask the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? -"Exercising during pregnancy is not recommended." -"Daily jogging for up to 30 minutes is fine throughout the pregnancy." -"Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." -"It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."

-"Daily jogging for up to 30 minutes is fine throughout the pregnancy." While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods.

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? -"I should drink about 2 liters of fluid each day." -"I should not drink alcoholic beverages during my pregnancy." -"I can have a moderate amount of caffeine daily." -"I should increase my calcium intake to 1,500 milligrams per day"

-"I should increase my calcium intake to 1,500 milligrams per day" A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass.

A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? -"I should start solid foods when my baby is 3 months old." -"I should introduce cow's milk when my baby is 9 months old." -"I should wait to give fruit juice until my baby is 6 months of age." -"I should wait to begin fluoride supplements until my baby is 4 months of age."

-"I should wait to give fruit juice until my baby is 6 months of age." Fruit juice provides minimal nutritional value to the infant's diet. Therefore, fruit juices should be limited and not offered until the infant is 6 months of age.

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching? -"I will have to lie on my back during the test." -"My baby's heart rate will be monitored during the test." -"I should schedule the test when the baby is usually active." -"It will take 20 to 30 minutes to complete the test."

-"I will have to lie on my back during the test." The client is placed in a Semi-Fowler's position with one hip slightly elevated to promote uterine perfusion and prevent supine hypotension as a result of the uterus compressing the maternal vena cava.

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching? -"I should limit my carbohydrates to 50% of caloric intake." -"I will reduce my exercise schedule to 3 days a week." -"I will take my glyburide daily with breakfast." -"I know I am at increased risk to develop type 2 diabetes."

-"I will reduce my exercise schedule to 3 days a week." Increased exercise benefits the client and can result in improved management of gestational diabetes.

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? -"I will reduce my stress level." -"I will tell my doctor before using home remedies for nausea." -"I will monitor my weight gain during the remaining months." -"I will use only nonprescription medications while pregnant."

-"I will use only nonprescription medications while pregnant." Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy.

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency an asks if this will continue until delivery. Which of the following responses should the nurse make? -"It's a minor inconvenience, which you should ignore." -"In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." -"There is no way to predict how long it will last in each individual client." -"It occurs during the first trimester and near the end of the pregnancy."

-"It occurs during the first trimester and near the end of the pregnancy." Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and ask the nurse about the purpose of this medication. The nurse should provide which of the following explanations? -"It is used to stop preterm labor contractions." -"It halts cervical dilation." -"It promotes fetal lung maturity." -"It increases the fetal heart rate."

-"It promotes fetal lung maturity." Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant.

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make? -"It sounds like you are feeling sad that things didn't go as planned." -"At least you know you have a healthy baby." -"Maybe next time you can have a vaginal delivery." -"You can resume sexual relations sooner than if you had delivered vaginally."

-"It sounds like you are feeling sad that things didn't go as planned." This response uses the therapeutic communication technique of restating to encourage the client to continue to communicate her feelings.

A nurse is preparing an in-service about St. John's wort. Which of the following information should the nurse include in the teaching? "St. John's wort potentiates the hypoglycemic effects of a client's antidiabetic medication." "St. John's wort provides an anti-inflammatory effect." "St. John's wort can cause photophobia." "St. John's wort can delay diagnosing prostate cancer in some clients."

-"St. John's wort can cause photophobia." The nurse should teach the client that St. John's wort may cause photophobia; therefore, the client should wear protective clothing, sun screen, and sun-glasses when outside.

A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching? -"The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." -"The sex of the baby is determined by week 8 of pregnancy." -"Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy." -"You will first feel your baby move in week 24 of pregnancy."

-"The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation.

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? -"It would be best if you gained about 11 to 20 pounds." -"The recommendation for you is about 15 to 25 pounds." -"A gain of about 25 to 35 pounds is recommended for you." -"A gain of about 1 pound per week is the best pattern for you."

-"The recommendation for you is about 15 to 25 pounds." Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb). The pattern of weight gain is also important, with minimal gain in the first trimester.

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? -"These exercises help prevent constipation." -"These exercises help pelvic muscles to stretch during birth." -"They can help reduce back aches." -"They can prevent further stretch marks."

-"These exercises help pelvic muscles to stretch during birth." Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth.

A nurse is caring for a client who is at 37 week s of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? -"There is an increased risk of introducing infection." -"This could initiate preterm labor." -"This could result in profound bleeding." -"There is an increased risk of rupture of the membranes."

-"This could result in profound bleeding." "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? -"This infection is treated with one dose of azithromycin." -"If your sexual partner has no symptoms, no medication is needed." -"You have to avoid sexual relations for 3 days." -"You need to return in 6 months for retesting."

-"This infection is treated with one dose of azithromycin." A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.

A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? -"This is a presumptive sign of pregnancy." -"This is a probable sign of pregnancy." -"This is a possible sign of pregnancy." -"This is a positive sign of pregnancy."

-"This is a presumptive sign of pregnancy." Presumptive signs of pregnancy include physical changes that are apparent to the client, such as quickening.

A nurse in a prenatal clinic is instructing a client about an aminocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching? -"The test will be performed if your baby's heart beat is heard." -"This test will determine if your baby's lungs are mature." -"This test requires the presence of amniotic fluid." -"After the test, you will be given Rho immune globulin since you are Rh positive."

-"This test requires the presence of amniotic fluid." Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation.

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? -"This will occur during the last trimester of pregnancy." -"This will happen by the end of the first trimester of pregnancy." -"This will occur between the fourth and fifth months of pregnancy." -"This will happen once the uterus begins to rise out of the pelvis."

-"This will occur between the fourth and fifth months of pregnancy." Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks.

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? -"What part of the exam makes you most nervous?" -"Don't worry, I will be with you during the exam." -"All you need to do is relax." -"A pelvic exam is required if you want birth control pills."

-"What part of the exam makes you most nervous?" This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns.

A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? -"You should not receive the rubella vaccine while breastfeeding." -"You should receive a varicella vaccine before you deliver." -"You can receive an influenza vaccination during pregnancy." -"You cannot receive the Tdap vaccine until after you deliver."

-"You can receive an influenza vaccination during pregnancy." It is recommended that pregnant women receive annual influenza vaccinations.

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? -"You must be feeling scared and powerless." -"Everyone worries about her baby when she's in labor." -"Your pregnancy is advanced so your baby should be fine." -"We have a neonatal unit here that's equipped to handle emergencies."

-"You must be feeling scared and powerless." This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client.

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make? -"Give your parents a chance; they'll understand." -"If you want me to, I can tell your parents for you." -"You seem scared to talk to your parents." -"Your parents will have to be told why you are being admitted."

-"You seem scared to talk to your parents." This is an open-ended therapeutic statement that focuses on the adolescent's concern and allows for further exploration of the client's fear of telling her parents that she is sexually active.

This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy. -"You should go ahead and push to assist the delivery." -"You should try to pant as the delivery proceeds." -"You should try to perform slow-paced breathing." -"You should take a deep, cleansing breath and breathe naturally."

-"You should try to pant as the delivery proceeds." Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head.

A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? -A 26-year-old client who has migraine headaches at the start of each menstrual cycle -A 28-year-old client who has a history of pelvic inflammatory disease -A 32-year-old client who has benign breast disease -A 38-year-old client who reports smoking one pack of cigarettes every day

-A 38-year-old client who reports smoking one pack of cigarettes every day A client who is over the age of 35 and smokes is at increased risk of thromboembolism.

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? -At the level of the umbilicus -2 cm above the umbilicus -One fingerbreadth above the symphysis pubis -To the right of the umbilicus

-At the level of the umbilicus Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day.

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first? -A client who experienced a cesarean birth 4 hr ago and reports pain -A client who has preeclampsia with a BP of 138/90 mm Hg -A client who experienced a vaginal birth 24 hr ago and reports no bleeding -A client who is scheduled for discharge following a laparoscopic tubal ligation

-A client who experienced a cesarean birth 4 hr ago and reports pain Using Maslow's hierarchy of needs, assessment of pain and meeting the physiological needs of a surgical client are the priority nursing actions.

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately? -A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions -A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors -A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes -A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache

-A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache These findings indicate that the client's condition is worsening and are signs of severe preeclampsia. They should be reported to the provider immediately. Other manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant pain.

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first? -A client who is at 38 weeks of gestation and reports a cough and fever -A client who has missed a period and reports vaginal spotting -A client who is at 14 weeks of gestation and reports nausea and vomiting -A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

-A client who is at 28 weeks of gestation and reports of painless vaginal bleeding Using the urgent vs. nonurgent approach to client care, the nurse should assess this client first. The nurse should suspect placenta previa when vaginal bleeding occurs after 24 weeks of gestation. A pregnant woman can lose up to 40% of blood before showing signs of shock.

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? -A client who is experiencing fetal death at 32 weeks of gestation -A client who is experiencing preterm labor at 26 weeks of gestation -A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation -A client who has a post-term pregnancy at 42 weeks of gestation

-A client who is experiencing preterm labor at 26 weeks of gestation Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks of gestation is a candidate for tocolytic therapy.

A nurse is caring for a client during a nonstress test (NST). At the end of a 30 min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decerlations of 15/min in the FHR during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? -A negative test -A nonreactive test -A positive test -A reactive test

-A nonreactive test An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds.

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? -Decreased vaginal discharge -A surge of energy -Urinary retention -Weight gain of 0.5 to 1.5 kg

-A surge of energy Prior to the onset of labor, the pregnant client experiences a surge of energy.

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? -Placenta previa -Prolapsed cord -Incompetent cervix -Abruptio placentae

-Abruptio placentae The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions.

A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take? -Infuse a bolus of IV fluid. -Administer hydralazine 25 mg IV. -Prepare the client for immediate delivery. -Administer betamethasone 12 mg IM.

-Administer betamethasone 12 mg IM. Betamethasone is classified as a corticosteroid medication. Corticosteroids are often administered to the mother to assist in fetal lung maturity. These are usually administered by IM injection of 12 mg for the first two doses. The subsequent dosing should be 6 mg by IM every 12 hr x 4 doses.

A nurse is admitting a client who is at 37 weeks of gestation and has a severe gestational hypertension. Which of the following actions should the nurse expect to implement? SATA -Administer magnesium sulfate IV. -Provide a dark, quiet environment. -Assess respiratory status every 4 hr. -Evaluate neurologic status every 8 hr. -Ensure that calcium gluconate is readily available.

-Administer magnesium sulfate IV. -Provide a dark, quiet environment. -Ensure that calcium gluconate is readily available. Administer magnesium sulfate IV is correct. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L. Provide a dark, quiet environment is correct. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. Assess respiratory status every 4 hr is incorrect. The nurse should monitor the client's respiratory status closely because the client is at risk for respiratory depression. During an infusion of magnesium sulfate, the nurse should monitor the respiratory rate every 5 min and every 15 min during maintenance infusion. Depending on the client's response to the medication, the provider will prescribe for the vital signs to be monitored every 30 to 60 min thereafter. Evaluate neurologic status every 8 hr is incorrect. The nurse should evaluate the client's level of consciousness every hour. Ensure that calcium gluconate is readily available is correct. Calcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress.

A nurse in a prenatal clinic is caring for a client who ask what he estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse -February 11, 2016 -February 27, 2016 -April 27, 2016 -April 11, 2016

-February 11, 2016 Subtracting 3 calendar months and adding 7 days plus one year will result in this estimated date of delivery.

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? -Assess deep tendon reflexes every hour. -Obtain a daily weight. -Continuous fetal monitoring -Ambulate twice daily.

-Ambulate twice daily. A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental blood flow.

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following? -The client is carrying more than one fetus. -There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid. -An excessive amount of amniotic fluid is present. -The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor.

-An excessive amount of amniotic fluid is present. An excess of amniotic fluid is defined as amniotic fluid pockets of >8 cm or an amniotic fluid index of greater than 25. Polyhydramnios or hydramnios is associated with neural tube defects, obstructions of the fetal gastrointestinal tract, multiple fetuses, and fetal hydrops.

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A male condom An intrauterine device (IUD) An oral contraceptive A diaphragm with spermicide.

-An intrauterine device (IUD) An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception.

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? SATA -Rh incompatibility -Cephalopelvic disproportion -Anomalies in fetal chromosomes -Neural tube defects -Fetal gender

-Anomalies in fetal chromosomes -Neural tube defects -Fetal gender Rh incompatibility is incorrect. An indirect Coombs test is a screening tool for Rh incompatibility. Cephalopelvic disproportion is incorrect. Abdominal ultrasonography is used to identify cephalopelvic disproportion later in pregnancy. Anomalies in fetal chromosomes is correct. Examination of amniotic fluid yields data about genetic anomalies, such as hemophilia and inborn metabolic disorders. Neural tube defects is correct. Examination of alpha fetoprotein levels in amniotic fluid confirms the presence of a neural tube defect, such as spina bifida. Fetal gender is correct. Karyotyping of fetal cells obtained from amniotic fluid permits the identification of fetal gender, which is important if an X-linked disorder is suspected in a male fetus.

A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? -Antihypertensives -Anticonvulsants -Antioxidants -Antiemetics

-Anticonvulsants Anticonvulsants when taken simultaneously with COCs can decrease their effectiveness. The anticonvulsants included are: phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, and primidone.

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? -Monitor vaginal bleeding. -Administer glucocorticoids. -Insert an IV catheter. -Apply an external fetal monitor.

-Apply an external fetal monitor. Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take? -Cut the umbilical cord. -Apply perineal pressure to the emerging fetal head. -Prevent the perineum from tearing. -Promote delivery of the placenta.

-Apply perineal pressure to the emerging fetal head. Using Maslow's hierarchy of needs, the priority intervention is to prevent injury to the fetus during the delivery by applying gentle perineal pressure to the emerging head. This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull due to a rapid delivery can cause neurologic damage (increased intracranial pressure and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations.

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? -Observe color and consistency of fluid. -Assess the fetal heart rate pattern. -Assess the client's temperature. -Evaluate client for the presence of chills and increased uterine tenderness using palpation.

-Assess the fetal heart rate pattern. Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? -Monitor the client's temperature. -Assess the fetal heart rate. -Assess the odor of the amniotic fluid. -Provide clean, dry underpads.

-Assess the fetal heart rate. The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? -Recheck the client's temperature in 4 hr. -Administer glucocorticoids intramuscularly. -Assess the odor of the amniotic fluid. -Prepare the client for emergency cesarean section.

-Assess the odor of the amniotic fluid. Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid.

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? -Administer oxygen via nasal cannula. -Assist the client to breathe into a paper bag. -Have the client tuck her chin to her chest. -Instruct the client to increase her respiratory rate to more than 42 breaths per min.

-Assist the client to breathe into a paper bag. This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? -The client reports weakness of the lower extremities. -Blood pressure 80/56 mm Hg -Temperature 38.2°C (100.8°F) -The client reports perfuse itching.

-Blood pressure 80/56 mm Hg When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? -Vertex -Shoulder -Breech -Mentum

-Breech An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? -Cervical dilation -Report of pain above the umbilicus -Brownish vaginal discharge -Amniotic fluid in the vaginal vault

-Cervical dilation Cervical dilation and effacement are indications of true labor.

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? -Apply a fetal scalp electrode. -Increase the rate of the IV infusion. -Administer oxygen at 10 L/min via a nonrebreather mask. -Change the client's position.

-Change the client's position. The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognized as a sign of true labor? -Rupture of the membranes -Changes in the cervix -Station of the presenting part -Pattern of contractions

-Changes in the cervix Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

A nurse is creating the plan of care for a client who is at 39 week of gestation and in active labor. Which of the following actions should the nurse include in the plan of care? - Keep four side rails up while the client is in bed. -Check the cervix prior to analgesic administration -Monitor the fetal heart rate (FHR) every hour. -Insert an indwelling urinary catheter.

-Check the cervix prior to analgesic administration Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn.

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? -Limit alcohol consumption. -Increase intake of iron-rich foods. -Consume foods fortified with folic acid. -Avoid foods containing aspartame.

-Consume foods fortified with folic acid. Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? -Expulsion of a blood-tinged mucous plug -Continuous contraction lasting 2 min -Pressure on the perineum causing the client to bear down -Expulsion of clear fluid from the vagina

-Continuous contraction lasting 2 min A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? -Contractions lasting longer than 90 seconds -Contractions occurring every 3 to 5 min -Contractions are strong in intensity -Client reports feeling contractions in lower back

-Contractions lasting longer than 90 seconds A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? -Contractions that last for 60 seconds each with a 4-min rest between contractions -A contraction that lasts 4 min followed by a period of relaxation -Contractions that last for 60 seconds each with a 3-min rest between contractions -Contractions that last 45 seconds each with a 3-min rest between contractions

-Contractions that last for 60 seconds each with a 3-min rest between contractions A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.

A nurse in the emergency department is caring for a client who comes to the emergency department reporting sever abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicated to the nurse that the client has blood in the peritoneum? -Chvostek's sign -Cullen's sign -Chadwick's sign -Goodell's sign

-Cullen's sign Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? -1+ pitting sacral edema -3+ protein in the urine -Blood pressure 148/98 mm Hg -Deep tendon reflexes of +1

-Deep tendon reflexes of +1 Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex.

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? -Decrease the rate of infusion of the maintenance IV solution. -Discontinue the infusion of the IV oxytocin. -Increase the rate of infusion of the IV oxytocin. -Slow the client's rate of breathing.

-Discontinue the infusion of the IV oxytocin. Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.

A nurse is caring for a client who has preeclampsia and is being treated with mag sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? -Discontinue the medication infusion. -Prepare for an emergency cesarean birth. -Assess maternal blood glucose. -Place the client in Trendelenburg position.

-Discontinue the medication infusion. Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV.

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechia and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? -Anaphylactoid syndrome of pregnancy -Disseminated intravascular coagulation -Preeclampsia -Puerperal infection

-Disseminated intravascular coagulation Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? -Placing the newborn on a warm surface -Preventing air drafts -Drying the newborn's skin thoroughly -Maintaining ambient room temperature at 24° C (75° F)

-Drying the newborn's skin thoroughly Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? -Headaches -Nervousness -Tremors -Dyspnea

-Dyspnea The presence of dyspnea is a manifestation of pulmonary edema, which is a potentially life-threatening complication of terbutaline. This finding should be reported to the provider immediately.

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder? -Increased urine output -Vaginal discharge -Elevated blood pressure -Joint pain

-Elevated blood pressure Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.

A nurse is teaching a client who is at 23 weeks of gestation an will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client? -Food and fluids should not be consumed the day of the procedure. -Complete a bowel prep protocol the day before the procedure. -Empty her bladder immediately prior to the procedure. -Wash her abdomen with soap and water the morning of the procedure.

-Empty her bladder immediately prior to the procedure. Emptying the bladder before amniocentesis prevents possible puncture of the bladder and displacement of the uterus and fetus.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? -Maintain the client in the lithotomy position. -Perform vaginal examinations frequently. -Remind the client to bear down with each contraction. -Encourage the client to empty her bladder every 2 hr.

-Encourage the client to empty her bladder every 2 hr. A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

A nurse is instructing a female client about how to check basal temp in order to determine if the client is ovulating. The nurse should instruct the client to check her temp at which of the following times? -Every morning before arising -On days 13 to 17 of her menstrual cycle -1 hour following intercourse -Before going to bed every night

-Every morning before arising To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly.

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? -Rapid decline in human chorionic gonadotropin (hCG) levels -Profuse, clear vaginal discharge -Irregular fetal heart rate -Excessive uterine enlargement

-Excessive uterine enlargement A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia.

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? -Leukorrhea -Urinary frequency -Nausea and vomiting -Facial edema

-Facial edema Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider.

A nurse is caring for a client who is to undergo a biophysical profile. The client ask the nurse what is being evaluated during this test. Which of the following should the nurse include? SATA -Fetal breathing -Fetal motion -Fetal neck translucency -Amniotic fluid volume -Fetal gender

-Fetal breathing -Fetal motion -Amniotic fluid volume Fetal breathing is correct. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. Fetal motion is correct. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. Fetal neck translucency is incorrect. Fetal neck, or nuchal translucency, also called NT screening, is a separate evaluation tool that can be performed using ultrasound. Amniotic fluid volume is correct. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. Fetal gender is incorrect. Fetal gender can be identified via ultrasound but is not included in a biophysical profile.

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? -Fetal attitude is in general flexion. -Fetal lie is longitudinal. -Maternal pelvis is gynecoid. -Fetal position is persistent occiput posterior.

-Fetal position is persistent occiput posterior. The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief.

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus. -Calcium -Iron -Vitamin C -Folic acid

-Folic acid Adequate amounts of folic acid before conception and during the first trimester of pregnancy are necessary for fetal neural tube development. This vitamin helps prevent spina bifida and other neurological disorders.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? -Cephalic -Transverse -Posterior -Frank breech

-Frank breech With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? -Fundus firm to palpation -Increase in blood pressure -Increase in lochia -Report of absent breast pain

-Fundus firm to palpation Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy? -Gradual lordosis -Increased abdominal muscle tone -Posterior neck flexion -Decreased mobility of pelvic joints

-Gradual lordosis Clients who are pregnant can develop a gradual, forward curving of the spine as the growth of the fetus pulls the pelvis forward. This lordosis resolves after delivery.

A nurse is caring for a client who is in active labor with 7cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? -Assist the client into a comfortable position. -Observe the perineum for signs of crowning. -Have the client pant during the next contractions. -Help the client to the bathroom to void.

-Have the client pant during the next contractions. Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.

A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS. -High-absorbency tampons -Mosquito bites -Travel to foreign countries -Multiple sexual partners

-High-absorbency tampons Toxic shock syndrome, a severe disease caused by a toxin made by Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. Approximately 50% of all cases involve menstruating women using highly absorbent tampons.

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following finding should the nurse expect? SATA -History of migraines -Nulliparous -Twin gestations -History of gestational hypertension -Oligohydramnios

-History of migraines -Nulliparous -Twin gestations History of migraines is correct. History of migraines is a risk factor for hyperemesis gravidarum, which typically occurs during the first 20 weeks of pregnancy. Nulliparous is correct. Hyperemesis gravidarum is more common in nulliparous women, beginning in the first trimester. Clinical manifestations can continue throughout the pregnancy in some women. Twin gestations is correct. Twin gestations are a risk factor for hyperemesis gravidarum and might be related to increasing hormone levels of estrogen, progesterone, and human chorionic gonadotropin (hCG). History of gestational hypertension is incorrect. A history of gestational hypertension is not a risk factor for hyperemesis gravidarum. Oligohydramnios is incorrect. Oligohydramnios is not a risk factor for hyperemesis gravidarum.

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? -Cocaine use -Hypertension -Blunt force trauma -Cigarette smoking

-Hypertension Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? -Vomiting -Tachycardia -Respiratory depression -Hypotension

-Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client ask about the cause of her heartburn. Which of the following responses should the nurse make? -Retained bile in the liver results in delayed digestion. -Increased estrogen production causes increased secretion of hydrochloric acid. -Pressure from the growing uterus displaces the stomach. -Increased progesterone production causes decreased motility of smooth muscle.

-Increased progesterone production causes decreased motility of smooth muscle. Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn.

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? SATA -Prostaglandin E2 -Indomethacin -Magnesium sulfate -Methylergonovine -Oxytocin

-Indomethacin -Magnesium sulfate Prostaglandin E2 is incorrect. Prostaglandin E2 is used to stimulate cervical ripening and hasten the onset of labor. Indomethacin is correct. Indomethacin is used to relax uterine smooth muscles and suppress uterine activity in clients who have a diagnosis of preterm labor. Magnesium sulfate is correct. Magnesium sulfate is a tocolytic and stops contractions in clients experiencing preterm labor. Methylergonovine is incorrect. Methylergonovine promotes uterine contractions to manage postpartum hemorrhage. Oxytocin is incorrect. Oxytocin is used to induce and augment labor.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? -Insert an indwelling urinary catheter. -Initiate IV access. -Witness the signature for informed consent for surgery. -Prepare the abdominal and perineal areas.

-Initiate IV access. Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? -Cover the cord with a sterile, moist saline dressing. -Prepare the client for an immediate birth. -Place the client in knee-chest position. -Insert a gloved hand into the vagina to relieve pressure on the cord.

-Insert a gloved hand into the vagina to relieve pressure on the cord. This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client? -Acarbose -Repaglinide -Insulin -Glipizide

-Insulin Insulin is the first line of treatment for clients who are pregnant and are unable to maintain blood glucose levels within the recommended range. Unlike oral hyperglycemics, insulin does not cross the placenta and affect the fetus.

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the clients newborn at risk for which of the following complications? -Hearing loss -Intrauterine growth restriction -Type 1 diabetes mellitus -Congenital heart defects

-Intrauterine growth restriction Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death.

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? -This test assesses fetal lung maturity. -It assesses various markers of fetal well-being. -This test identifies an Rh incompatibility between the mother and fetus. -It is a screening test for spinal defects in the fetus.

-It is a screening test for spinal defects in the fetus. The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected neural tube defects (NTDs) and abdominal wall defects. These include spina bifida, microcephaly, and anencephaly. This tool is the basis for further testing, such as amniocentesis and specialized ultrasounds.

A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature? -Phosphatidylglycerol (PG) absent -Biophysical profile score of 8 -Lecithin/sphingomyelin (L/S) ratio of 2:1 -Nonstress test is reactive

-Lecithin/sphingomyelin (L/S) ratio of 2:1 An L/S ratio of 2:1 is an indication of fetal lung maturity.

A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? SATA -Eczema -Psoriasis -Linea nigra -Chloasma -Striae gravidarum

-Linea nigra -Chloasma -Striae gravidarum Eczema is incorrect. Eczema manifests as red, swollen, and itchy skin and is not an expected finding during pregnancy. Psoriasis is incorrect. Psoriasis manifests as thick red patches or plagues covered by silver scales on the skin and is not an expected finding during pregnancy.Linea nigra is correct. Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma is correct. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy.Striae gravidarum is correct. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy.

A nurse is caring for a client who is at 36 weeks of gestation and who has suspected placenta previa. Which of the following findings support this diagnosis? -Painless red vaginal bleeding -Increasing abdominal pain with a nonrelaxed uterus -Abdominal pain with scant red vaginal bleeding -Intermittent abdominal pain following passage of bloody mucus

-Painless red vaginal bleeding Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester.

A charge nurse observes a nurse checking fetal heart tones (FHT) for a client who is at 12 weeks of gestation. Which of the following actions by the nurse indicates a need for intervention by the charge nurse? -Places a pillow under the client's head -Counts the fetal heart rate for a full minute -Auscultates above the symphysis pubis -Listens with a fetoscope

-Listens with a fetoscope A fetoscope is not able to detect FHT this early in the pregnancy. The nurse should use a Doppler or ultrasound stethoscope. Typically at 12 weeks, the heart tones will be heard midline just above the symphysis pubis with a Doppler or ultrasound device. A fetoscope can be used to assess FHT later in the pregnancy, around 16 to 20 weeks.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? -Fetal lung maturity -Location of the placenta -Viability of the fetus -The biparietal diameter

-Location of the placenta Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? -Administer prescribed analgesic medication. -Encourage the client to rest between contractions. -Massage the client's back. -Turn the client onto her left side.

-Massage the client's back. The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client's back focuses on neuromuscular and cognitive changes.

A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings? Incomplete miscarriage Missed miscarriage Inevitable miscarriage Complete miscarriage

-Missed miscarriage With a missed miscarriage, the fetus has died but the client retains the products of conception for several weeks. The client might have spotting or no bleeding at all.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? -Apply fundal pressure. -Observe for the presence of a nuchal cord. -Observe for crowning. -Prepare to administer oxytocin.

-Observe for crowning. In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care? Observe for meconium in respiratory secretions. Monitor for hyperglycemia. Identify manifestations of anemia. Monitor for hyperthermia.

-Observe for meconium in respiratory secretions. When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery.

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? -Have the client stand at the bedside with her arms at her side. -Administer a 500 mL bolus of 5% dextrose in water prior to induction. -Inform the client the anesthetic effect will last for approximately 6 hr. -Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction.

-Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care? -Administer oxygen via nasal cannula. -Offer option to view products of conception. -Instruct the client to increase potassium-rich foods in the diet. -Maintain the client on bed rest.

-Offer option to view products of conception. Providing support for pregnancy loss includes offering the client and her partner the options of viewing the products of conception and making arrangements for handling of the fetal remains. The client should be instructed on possible grief responses, how to manage these, and provided a referral to a support group.

A nurse is caring for a client who is having a nonstress test performed. The FHR is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? -Immediately report the situation to the client's provider and prepare the client for induction of labor. -Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. -Offer the client a snack of orange juice and crackers. -Turn the client onto her left side.

-Offer the client a snack of orange juice and crackers. A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement.

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time? -Palpate the client's uterine fundus. -Assist the client on a bedpan to urinate. -Prepare to administer oxytocic medication. -Increase the client's fluid intake.

-Palpate the client's uterine fundus. Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client's fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? -Elevate the client's legs. -Monitor vital signs every 5 min. -Notify the provider. -Place the client in a lateral position

-Place the client in a lateral position Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? -Place the client in the lateral position. -Increase the rate of maintenance IV infusion. -Elevate the client's legs. -Administer oxygen using a nonrebreather mask.

-Place the client in the lateral position. This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? -Abruptio placentae -Placenta previa -Precipitous labor -Threatened abortion

-Placenta previa Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.

A nurse is caring for a client who is in active labor and notes late deceleration on the fetal monitor. Which of the following is the priority nursing action? -Elevate the client's legs. -Position the client on her side. -Administer oxygen via face mask. -Increase the infusion rate of the IV fluid.

-Position the client on her side. Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? -Postpartum infection -Hypertension -Postpartum hemorrhage -Thromboembolic events

-Postpartum hemorrhage Methylergonovine is an oxytocic medication. It causes uterine contractions, which control postpartum bleeding.

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? -Examination to determine cervical status -A magnesium sulfate infusion -Initiation of pushing -Preparation for cesarean birth

-Preparation for cesarean birth A cesarean birth is indicated for all clients who have a confirmed placenta previa.

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? -Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. -Observe an area of redness on the breast of a client who is 1 day postpartum. -Monitor vital signs during admission of a client who has gestational hypertension. -Change the perineal pad of a client who just transferred from labor and delivery.

-Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.

A nurse is caring for a client who is at 18 week s of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? -Ballottement -Lightening -Quickening -Chloasma

-Quickening Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement.

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? -Tachycardia -Absence of clonus -Polyuria -Report of headache

-Report of headache Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider? -Respiratory depression -Facial flushing -Nausea -Drowsiness

-Respiratory depression Magnesium sulfate toxicity can cause life-threatening adverse effects, including respiratory and CNS depression. The nurse should report a respiratory rate slower than 12/min immediately to the provider and stop the infusion.

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? -Diminished deep-tendon reflexes -Respiratory rate of 16/min -Urine output of 50 mL in 4hr -Heart rate of 56/min

-Respiratory rate of 16/min The client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. Based on this finding, the nurse may continue the infusion.

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? Left lower Right lower Left upper Right upper

-Right upper Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? -Shortly after giving birth -In the third trimester -Immediately -During her next attempt to get pregnant

-Shortly after giving birth The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? -3 cm above the umbilicus -Slightly above the umbilicus -Slightly below the umbilicus -3 cm below the umbilicus

-Slightly above the umbilicus At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation.

A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use? -The client is 42 years old. -The client smokes cigarettes. -The client has pelvic relaxation. -The client has a 3-month-old infant.

-The client has pelvic relaxation. Pelvic relaxation and large cystocele are contraindications for diaphragm use.

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretations of this data? -The client is not experiencing a rubella infection at this time. -The client is immune to the rubella virus. -The client requires a rubella vaccination at this time. -The client requires a rubella immunization following delivery.

-The client requires a rubella immunization following delivery. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? -The fetal head is in the left occiput posterior position. -The largest fetal diameter has passed through the pelvic outlet. -The posterior fontanel is palpable. -The lowermost portion of the fetus is at the level of the ischial spines.

-The lowermost portion of the fetus is at the level of the ischial spines. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? -The presenting part is 1 cm above the ischial spines. -The presenting part is 1 cm below the ischial spines. -The cervix is 1 cm dilated. -The cervix is effaced 1 cm.

-The presenting part is 1 cm above the ischial spines. Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? -There is evidence of cervical incompetence. -There is no evidence of two or more accelerations in fetal heart rate in 20 min. -There is no evidence of uteroplacental insufficiency. -There are less than 3 uterine contractions in a 10-min period.

-There is no evidence of uteroplacental insufficiency. A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations.

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? -Palpate the client's uterus. -Administer oxygen to the client. -Increase the client's IV fluid infusion rate. -Turn the client onto her side.

-Turn the client onto her side. When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin administration, or several other complicating factors. The client might be exerting pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? -Two veins and one artery -One artery and one vein -Two arteries and one vein -Two arteries and two veins

-Two arteries and one vein The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta.

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identity as consistent with the diagnosis? -Severe nausea and vomiting -Large amount of vaginal bleeding -Unilateral, cramp-like abdominal pain -Uterine enlargement greater than expected for gestational age

-Unilateral, cramp-like abdominal pain An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix.

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? -Respirations 16/min -Headache for 30 min -Urinary output 40 mL in 2 hr -Fetal heart rate 158/min

-Urinary output 40 mL in 2 hr Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr to the provider immediately and discontinue the medication.

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? -Uteroplacental insufficiency -Maternal bradycardia -Umbilical cord compression -Fetal head compression

-Uteroplacental insufficiency The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.

A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? -Vaginal intercourse can be resumed after 2 weeks. -Products of conception will be present in vaginal bleeding. -Increased intake of zinc-rich foods is recommended. -Aspirin may be taken for cramps.

-Vaginal intercourse can be resumed after 2 weeks. The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge.

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? -Early decelerations -Accelerations -Late decelerations -Variable decelerations

-Variable decelerations Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus.

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? -Variable decelerations are due to umbilical cord compression. -Variable decelerations are caused by uteroplacental insufficiency. -Variable decelerations are a result of the administration of IV narcotic analgesics. -Variable decelerations are related to fetal head compression.

-Variable decelerations are due to umbilical cord compression. Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.

A nurse is caring for a client who is at 28 weeks of gestations and received terbutaline. Which of the following findings should the nurse expect? -Fetal heart rate 100/min -Weakened uterine contractions -Enhanced production of fetal lung surfactant -Maternal blood glucose 63 mg/dL

-Weakened uterine contractions Terbutaline is a beta2-adrenergic agonist that acts to relax uterine smooth muscles. Terbutaline is used to stop contractions in a client who is experiencing preterm labor.

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha- fetoprotein (MSAFP) screening for which of the following clients? -A client who has mitral valve prolapse -A client who has been exposed to AIDS -All of the clients -A client who has a history of preterm labor

MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? -prepare for a cesarean birth -assist the client to an upright position -prepare for an immediate vaginal delivery -assist the client to turn onto her side

Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: FHR 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mmHg. Which of the following is the priority action for the nurse to take? -Notify the provider of the findings. -Position the client with one hip elevated. -Ask the client if she needs pain medication. -Have the client void.

Position the client with one hip elevated. Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.