maternity
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)
Answer C: The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse (C). An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. (A) should be assessed every 15 to 20 minutes during labor but is not specific for AROM. (B) is monitored hourly after the membranes are ruptured to detect development of amnionitis. (D) should be determined for all clients in labor.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? • Notify health care provider or anesthesiologist • Continue to assess BP every 5 min • Place the client in a lateral position • Turn off the continuous epidural
Answer C: The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol
What is the composition of colostrum compared to mature milk?
Colostrum- more protein (immunoglobulins), less sugar, less fat, less energy (kcal's), more sodium, potassium, chlorine -Breast milk in first 2-3 days after delivery. -Contains antibodies and immune system cells. -Shares mother's immunity with infant. -Protects against infections mother is immune to. -Kills disease causing infections in infant's digestive system.
• Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) a. Increased heartburn that is not relieved with doses of antacids B.Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C. Shoes and rings that are too tight because of peripheral edema in extremities D.Decrease in ability for the client to sleep for more than 2 hours at a time E. Chronic headache that has been lingering for a week behind the client's eyes
Answer A and E: Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.
• The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation
Answer A: Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. (B, C, and D) are incorrect.
A woman is to receive RhoGAM at 28 weeks' gestation. What action must the nurse take before giving the injection? • Validate that the baby is Rh negative. • Assess that the direct Coombs' test is positive. • Verify the identity of the woman. • Reconstitute the globulin with sterile water.
C: Although this is an important action that must be taken before the administration of any medication, it is espe- cially critical in this situation.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? • Reapply the external transducer. • Insert the intrauterine pressure catheter • Discontinue oxytocin infusion • Continue to monitor labor progress.
• Answer D: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.
Your patient who is 17 weeks pregnant describes to you she has been feeling the baby move. Which terms describes this movement?*• Quickening • Ballottement • Braxton Hick's contractions • None of the above because fetal movement isn't felt until 20 weeks gestation
Answer A: This patient is describing quickening which is where fetal movement is perceived and this can happen at 16 to 20 weeks of gestation.
Which of the following is a probable sign of pregnancy? • Quickening • Goodell's Sign • Amenorrhea • Fetal heart rate detected by electronic device
Answer B. Pregnancy signs are categorized into 3 categories: Presumptive, Probable, and Positive. Amenorrhea and quickening are presumptive signs of pregnancy, and fetal heart rate detected by an electronic devices is a positive sign of pregnancy. Out of this selection Goodell's sign is the only probable sign. Chadwick's sign and can happen as early as 6 weeks gestation.
A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O (negative), the baby's type is A (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? • Advise the client to keep her physician appointment at the end of the week in order to receive her RhoGAM injection. • Carefully check the record to make sure that the RhoGAM injection was administered. • Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. • Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.
Answer B: RhoGAM must be administered within 72 hours of delivery. The nurse should not finalize an Rh (negative) client's discharge until the client has received her RhoGAM injection. A negative di- rect Coombs' test means that no maternal antibodies were detected in the baby's cir- culatory system. The nurse would expect to detect a negative direct Coombs' test. This response is unacceptable. Rh- (negative) clients should receive their RhoGAM injection before 72 hours' postpartum or by discharge, whichever is earlier.
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D.February 6 to 7
Answer C: This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30 (C). (A, B, and D) are incorrect.
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? • Gravida 1, para 0 • Gravida 1, para 1 • Gravida 2, para 0 • Gravida 2, para 1
Answer C: This is the client's second pregnancy or second gravid event, so option C is correct. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a "para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? • Place a wedge under the client's left side. • Determine cervical dilation and effacement • Administer 10L of oxygen via facemask • Increase the rate of oxytocin (Pitocin) infusion.
Answer D: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.
A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, "I think I am engorged. My breasts are very hard and hot and they really hurt." Which of the following questions should the nurse ask at this time? • "Have you taken a warm shower this morning?" • "Do you have an electric breast pump?" • "How much did you have to drink yesterday?" • "When was the last time you fed the baby?"
Answer D: The nurse should ask the client when she fed the baby last. A warm shower may help to promote the milk ejection reflex, but this is not the question the nurse should ask at this time. The client may need to pump her breasts to soften them enough for the baby to latch well, but this is not the question the nurse should ask at this time. Unless a client has a very low intake, the quantity of fluids the client consumes is not related to the quantity of milk she will produce.
