Maternity HESI Questions & Hints

The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy?

The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client?

There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?

Transition labor with contractions every 2 minutes, lasting 90 seconds each.

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?

Two weeks before menstruation Rationale: 14 days before

Cord prolapse

Umbilical cord presents first during delivery and is seen within the cervix., Umbilical cord protruding through the cervix or adjacent to presenting fetal part. Re-position the mother to relieve pressure on the cord. KNEE- CHEST position.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?

Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.

Ultrasonography

Used to determine number of fetuses, presence of fetal cardiac movement and rhythm, Uterine abnormalities, gestational age.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness Rationale: In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

V - C E - H A - O L - P

Variable - Cord compression Early decelerations - Head compression Accelerations - Ok Late decelerations - uterine Placental insufficiency

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation?

Vernix is a white cheesy substance, predominantly located in the skin folds.

Patient Teaching : to immediately report any of the following danger signs:

Visual disturbances, Swelling of face, fingers, or sacrum. Sever continuous headaches Persistent vomiting. Infection is indicated by chills, temperature over 100.4 F Dysuria, Pain in the abdomen, Fluid discharge or bleeding from vagina. Change in fetal movement or increased fetal heart rate.

Nurse should look for maternal- fetal bonding during pregnancy.

Watch that the mother talks to the fetus' in utero, massaging abdomen, nicknaming the fetus are all healthy psychosocial activities.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color and asks when the flow will stop. How should the nurse respond?

When the placental site has healed Rationale: The placental site in the uterus usually heals in 3 to 6 weeks, and the lochial flow should cease at that time.

The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?

Yellowish tinge to the skin.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide?

Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant is adequately hydrated.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the

anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month (D).

Fetal Well-being.

assessing fundal height, fetal heart tones and rate, fetal movement, and uterine activity (contractions) Changes in fetal heart rate are the first and most important indicators of compromised blood flow to the fetus, and these changes require action.

Amniocentesis - Late in pregnancy

bladder must be empty so it will not be punctured.

Amniocentesis- early pregnancy

bladder must be full to help support the uterus and to help push the uterus up in the abdomen for easy access.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply: Uterine rigidity, Uterine tenderness, severe abdominal pain, bright red vaginal bleeidng, soft relaxed nontender uterus, fundal height greater than expected

bright red vaginal bleeding, soft relaxed nontender uterus, fundal height greater than expected

Nipple Stimulation

causes the posterior pituitary gland to release oxytocin. The danger of nipple stimulation lies in controlling the dose of oxytocin delivered by the posterior pituitary. the chance of hyperstumlation or tetany (contractions over 90 seconds or contractions with less than 30 seconds in between) is increased.

Low Risk Obstetric Visits

every 4 weeks until 28 weeks, every 2 weeks from 28-36 weeks, every week from 36 weeks until delivery.

Gestational Age

is best determined by an early sonogram than a later one.

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?

"Bend your foot toward your body while extending the knee when the cramps occur."

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

"Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

A decrease in respiratory rate from 24 to 16. Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.)

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

A normal test result

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic?

A softening of the cervix

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.)

A sterile glove. An amnihook. Lubricant.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy." Rationale: Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. What can I do for you? 2. Now you have an angel in heaven 3. Don't worry, there's nothing you could have done to prevent this from happening 4. We will see to it that you have an early discharge so you don't have to be reminded of this experience.

1. What can I do for you?

The nurse is monitoring a PP client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. changes in vital signs 2. signs of heavy bruising 3. complaints of intense pain 4. complaints of a tearing sensation

1. changes in vital signs

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the HCP? 1. urinary output has decreased 2. dependent edema has resolved 3. BP is at prenatal baseline 4. complaints of headache and blurry vision

1. complaints of headache and blurry vision

An ultra sound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the US indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. delivery of the fetus 2. strict I&O monitoring 3. complete bedrest for the rest of the pregnancy 4. weekly monitoring of coagulation studies until delivery

1. delivery of fetus

The nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting HIV? 1. history of IV drug use 2. significant other who is heterosexual 3. history of sexually transmitted infections 4. one sexual partner for the past 10 yrs

1. history of IV drug use

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. hypotonic 2. precipitous 3. hypertonic 4. preterm

1. hypotonic

The nurse is assessing a pregnant client with type 1 DM about her understanding regarding changing insulin needs during her pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. i need to increase my insulin during the first 3 months of pregnancy 2. my insulin dose will need to increase during the 2nd and 3rd trimesters 3. episodes of hypoglycemia are more likely in the first 3 months of pregnancy 4. insulin needs should return to normal 7-10 days after birth if i'm bottle-feeding

1. i need to increase my insulin during the first 3 months of pregnancy

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. provide pain relief measures 2. prepare client for an amniotomy 3. promote ambulation q30min 4. monitor oxytocin infusion closely

1. provide pain relief

The nurse is providing instructions to a pregnant client with HIV regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. you will need to bottle-feed your baby 2. you will need to feed your baby by NG tube 3. you will be able to breastfeed for 6 months and then will need to switch to bottle feeding 4. you will be able to breast-feed for 9 months and then will switch to bottle-feeding

1. you will need to bottle-feed your baby`

A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

14-18

A pp client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. providing sitz baths 2. encouraging fluid intake 3. placing ice on the perineum 4. monitor Hgb and Hct levels

2. encourage fluid intake

The nurse in the pp unit is caring for a client who has just delivered a newborn infant following a pregnancy with with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. infection 2. hemorrhage 3. chronic HTN 4. disseminated intravascular coagulation

2. hemorrhage

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35 y.o primigravida 2. the client has a hx of cardiac disease 3. the client's hbg is 13.5 4. the client is a 20 y.o. primigravida of average wt and ht

2. hx of cardiac disease

The nurse is monitoring a client in the immediate PP period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. temp of 100.4 2. an increase in HR from 88 to 102 3. BP change from 130/88 to 124/80 4. increase in RR from 18 to 22

2. increase in HR

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the HCP's prescriptions and should questions which one? 1. prepare client for an US 2. obtain equipment for a manual pelvic exam 3.prepare to draw a Hgb and Hct blood sample 4. obtain equipment for external electronic FHR monitoring

2. manual pelvic examination

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. provide comfort measures 2. monitor FHR 3. change client's position frequently 4. keep significant other informed of progress of labor

2. monitor FHR

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina 2. place the client in trendelenburg position 3. find the closest telephone and page the HCP stat 4. call the delivery room to notify staff that the client will be transported immediately

2. place the client in trendelenburg position

After a precipitous deliver, the nurse notes that the new mother is passive and only touches her newborn infant briefly wiht her fingertips. What should the nurse do to help the woman process the delivery? 1. encourage her to breastfeed soon after the birth 2. support her reaction to the newborn infant 3. tell the mother that it is important to hold her infant 4. document a complete account of the mother's reaction on the birth record

2. support her reaction to the newborn infant

The nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. soft abdomen 2. uterine tenderness 3. absence of abdominal pain 4. painless, bright red vaginal bleeding

2. uterine tenderness

it is recommended that pregnant women consume:

3 cups of milk or yogurt per day, This ensures that daily calcium needs are met. Helps to alleviate leg cramping.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. I should stay on the diabetic diet 2. I should perform glucose monitoring at home 3. I should avoid exercise 4. I should be aware of any infection and report signs of infection to the HCP as soon as possible.

3. I should avoid exercise because of the negative effects on insulin production

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. record the findings 2. massage the fundus 3. notify the HCP 4. place the client in trendelenburg position

3. Notify the HCP

The nurse in a maternity unit is reviewing client records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1. primigravida with mild preeclampsia 2. primigravida who delivered a 10lb infant 3hrs ago 3. gravida 2 who has just been diagnosed with dead fetus syndrome 4. gravida 4 who delivered 8hrs ago and has lost 500 mL of blood

3. a gravida 2 who has just been diagnosed with dead fetus syndrome

The pp nurse is assessing a client who delivered a healthy infant by C-sec for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if SVT were present? 1. paleness of calf 2. coolness of calf 3. enlarged, hardened veins 4. palpable dorsalis pedis pulses

3. enlarged, hardened veins

On assessment of a pp client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. elevate the client's legs 2. document the findings 3. massage fundus until it's firm 4. push on uterus to assist in expressing clots

3. massage fundus until it is firm

The nurse is reviewing the HCP's prescriptions for a client admitted for PROM. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. monitor FHR continuously 2. monitor maternal VS closely 3. perform a vaginal exam every shift 4. administer ampicillin 1g as an IV piggyback q6hrs

3. perform a vaginal exam every shift

The nurse is developing a plan of care for a PP client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. assess vital signs q4hrs 2. measure fundal ht q4hrs 3. prepare an ice pack for application to the area 4. inform the HCP of assessment findings

3. prepare an ice pack for application to the area

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding?

30cm Rationale: During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus' age in weeks ± 2 cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Englargement of breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding in gums, petechiae, and purpura

4. Evidence of bleeding in gums, petechiae, and purpura

The nurse is providing instructions about measures to prevent PP mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction? 1. I should breastfeed q 2-3 hrs 2. I should change the breast pads frequently 3. I should wash my hands before breastfeeding 4. I should wash my nipples daily with soap and water

4. I should wash my nipples daily with soap and water

A client in a pp unit complains of sudden sharp cx pain and dyspnea. The nurse notes that the client is tachycardic and the RR is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. initiate an IV 2. assess BP 3. prepare to administer morphine sulfate 4. administer oxygen

4. administer oxygen

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a C-sec birth, what is the most important nursing action? 1. slow IV flow rate 2. place in high fowler's position 3. continue pitocin drip if infusing 4. administer O2

4. administer oxygen, 8-10 mL/min via face mask

A pregnant client reports to a health care clinic, complaining of a loss of appetite, weight loss, and fatigue. After assessment of the client, TB is suspected. A sputum culture is obtained and identifies mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1. therapeutic abortion is required 2. she will need to stay at home until treatment is completed 3. medication won't be started until after delivery of fetus 4. isoniazid plus rifampin will be required for 9 months

4. isoniazid plus rifampin is required for 9 months

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. primiparous client who delivered 4 hours ago 2. multiparous client who delivered 6 hours ago 3. primiparous client who delivered 6 hours ago and had epidural anesthesia 4. multiparous client who delivered a large baby after oxytocin induction

4. multiparous client who delivered a large baby after oxytocin induction

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. maternal fatigue 2. coordinated uterine contractions 3. progressive changes in cervix 4. persistent nonreassuring FHR

4. persistent nonreassuring FHR

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?

5 Rationale: The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0 and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.

In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.)

A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/minute Rationale: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

Third Stage of Labor

Average length of 3rd stage of labor is 5 to 15 minutes, the longer the third stage of labor, the greater the chance for uterine atony or hemmorhage to occur.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?

Avoid alcohol because it is excreted in breast milk.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?

Cephalhematoma, which is caused by forceps trauma Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section?

Check the firmness of the uterus every 15 minutes.

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

Come to the clinic today for an ultrasound. Rationale: Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A).

A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?

Complete a sterile vaginal exam. A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.

A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus?

Connects the umbilical vein to the inferior vena cava

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?

Continue to monitor labor progress. Rationale: 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.

How to determine the due date

Count back three months and add 7 days.

Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)

Cramping with bright red spotting Lack of tenderness of the breast Increased right-side flank pain Rationale: 1&2 are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. 3 could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.)

Dark, red vaginal bleeding. Increased uterine irritability. A rigid abdomen.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?

Describe diet changes that can improve the management of her diabetes. Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?

Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority.

Checking the fetal heart rate

Doppler 10-12 weeks. Fetoscope from 15-20 weeks. NORMAL RANGE is 110-160 beats per minute.

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client?

Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with healthy lifestyles in the family (D) which is an intervention in preconception care that targets an overall goal for a client preparing for pregnancy.

The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?

Encourage the mother to breastfeed frequently. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin (C)

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant. Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?

Ensure that the baby is positioned correctly for latching on. Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement?

Extend the leg and dorsiflex the foot. Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B), and putting the heel of the foot on the floor is the best means of relieving leg cramps.

The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the info provided by the nurse? 1. i should increase my sodium intake during pregnancy 2. i should lower my blood volume by limiting fluids 3. i should maintain a low-cal diet to prevent weight gain 4. i should drink adequate fluids and increase intake of high fiber foods

4. i should drink adequate fluids and increase my intake of high-fiber foods

Normal pH for fetus (in labor)

7.25-7.35

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

14 days

Between ovulation and the beginning of the next menstrual cycle, there are usually exactly 14 days. Ovulation occurs 14 days before the next menstrual period.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?

Between the time the temperature falls and rises. In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?

Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate.

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?

Breastfeed the infant every 2 hours.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?

Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale: Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion (eclampsia) and requires immediate attention.

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?

Changes in apical heart rate from the 180s to the 140s. Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal (C) is one indicator that Epogen is effective.

The client comes to the hospital assuming she is in labor. Which assessment finding(s) by the nurse would indicate that the client is in true labor? (Select all that apply.)

Pain in the lower back that radiates to abdomen Progressive cervical dilation and effacement Regular and rhythmic painful contractions

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain?

Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the fetus.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

Delivery of the fetus Rationale: The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy.

During pregnancy a woman should add 300 calories and 3 cups of yogurt or calcium.

Diet

Pregnancy and Battery

For many women, battering begins during pregnancy (emotional or physical). Women should be assessed for abuse in private, AWAY from the male partner, by a nurse who is familiar with local resources and knows how to determine the safety of the client.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? select all that apply: proteinuria, hypertension, low-grade fever, generalized edema, increased pulse rate, increased respiratory rate

proteinuria, hypertension, generalized edema

Late decelerations indicate

uteroplacental insufficiency. and are associated with conditions such as post maturity, Preeclampsia, diabetes mellitus, cardiac disease and abruptio placenta.

Take client to bathroom or offer bedpan q 2 hours during labor.

Full bladder can impede labor. Usually a catheter is inserted.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?

Gonorrhea

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?

Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C).

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 2, para 0

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?

Grief related to her perceptions about the loss of this child.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide?

HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant's blood

List three necessary nursing actions prior to an ultrasound exam in the first trimester of pregnancy

Have client fill bladder. Do not allow client to void. Place her supine position and with uterine wedge.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?

Have her cup both hands over her nose and mouth while breathing. Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?

Have the client breathe into her cupped hands. Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands (C)

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice?

Hemoglobin 9.1 g/dL

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage Rationale: n placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?

Hypotonic Rationale: Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic dystocia usually occurs during the latent phase of labor, and contractions are painful, frequent, and usually uncoordinated. Precipitous labor is labor that lasts in its entirety for 3 hours or less. Preterm labor is the onset of labor after 20 weeks of gestation and before the thirty-seventh week of gestation.

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted?

If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. Rationale: Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent?

If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic collection of peritoneal dye/gas.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

Impaired bowel motility related to pain medication and immobility. Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

Increase IV rate. The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14-weeks gestation when embryonic growth expands the fallopian tube causing its rupture, and can result in hemorrage and hypovolemic shock. Increasing the IV infusion rate (C) provides intravascular fluid to maintain blood pressure.

The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester?

Increase in heart rate

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?

Increase the rate of the oxytocin (Pitocin) infusion Rationale: 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.

Which finding(s) is (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.)

Increased heartburn that is not relieved with doses of antacids Chronic headache that has been lingering for a week behind the client's eyes Rationale: 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.

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action?

Initiate a gentle upward tap on the cervix.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next?

Initiate positive pressure ventilation. The nurse should immediately begin positive pressure ventilation (A) because this infant's vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60 breaths/minute.) Waiting until the infant is 1 minute old to intervene may worsen the infant's condition. According to neonatal resuscitation guidelines, CPR is not begun until the heart rate is 60 or below or between 60 and 80 and not increasing after 20 to 30 seconds of PPV.

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?

It is difficult to consume 18 mg of additional iron by diet alone. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult (B) so iron supplements are often recommended.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?

It is important that you want to take part in your care.

Which explanation should the nurse provide to the prenatal client about the purpose of the placenta?

It is the way the baby gets food and oxygen.

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?

January 29 to 30 Rationale: 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

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is

January 30-31

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother?

Lower initial weight documented at birth

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?"

Lying prone with a pillow on the abdomen. Lying prone (A) keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.

Uterine Atony

Massage Fundus. Results from inability of uterine muscle to contract adequately after birth S/s Possible lateral displacement on palpitation and boggy Prolonged lochial discharge Irregular or excessive bleeding Tachycardia and hypotension.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

Meet the mother's physical needs and demonstrate warmth toward the infant. It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking (D).

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?

Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D).

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding.

Nursing Actions for Variable Deceleration Pattern:

Most common. Occurs in 40% of all labors and is caused mainly by cord compression or rapid fetal descent. Change Maternal position. Discontinue oxytocin if infusing. Administer 10 L of O2 by tight face mask. Perform a vaginal exam to check for cord compression. Report findings.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?

Move about ever hour. Rationale: Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return.

Most providers prescribe prenatal vitamins to ensure that the client receives an adequate intake of vitamins.

Must be prescribed by the HCP. Nurses must teach about proper diet, and taking the prescribed vitamins if they have been prescribed by the health care provider.

Discomforts of pregnancy

N&V, syncope, urinary frequency/urgency, breast tenderness, increased vaginal discharge, nasal stuffiness, fatigue, heartburn, varicose vein, headaches,

Nursing Actions for early decelerations

NONE required. Monitor progress of labor.

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding?

Normal

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse?

Notify HCP Rationale: The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

Notify the health care provider (HCP).

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)?

November 22 Rationale: Subtract 3 months, add 7 days.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

Observe for an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?

Observe the mother for other attachment behaviors.

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan?

Observe the parents applying a Pavlik harness. Rationale: It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness ; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first?

Obtain a serum glucose level. Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?

Obtain a specimen for urine analysis. Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination. Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?

Onset of uterine contractions.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next?

Palpate the firmness of the fundus.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

Patellar reflex 4+ A 4+ reflex in a client with pregnancy-induced hypertension (A) indicates hyperreflexia, which is an indication of an impending seizure.

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?

Place petroleum ointment around the glans with each diaper change and cleansing. Rationale: With each diaper change, the glans penis should be washed with warm water to remove any urine or feces and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 mm Hg to 90/60 mm Hg. Which action should the nurse take immediately?

Place the client in a lateral position. Rationale: 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 face mask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?

Place the client in a slight Trendelenburg position. Rationale: The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?

Place the woman in a lateral position. The nurse should immediately turn the woman to a lateral position (C), place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?

Postpartum blues

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures. Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Put baby to breast immediately. Rationale: The stimulation of breast milk with help clamp down the uterus to prevent postpartum hemorrhage.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?

Raise the foot of the bed. These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the client is in a lateral position are also appropriate interventions.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?

Reassure him that normal maternal-fetal bonding is occurring.

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?

Reduce activity level and notify the healthcare provider. Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare provider and reduce her activity to conserve energy (A).

Amniotcentesis

Removal of amniotic fluid sample from uterus as early as 14-16 weeks. Can determine sex of fetus, downs syndrome, tay-sachs, AFP elevations which are associated with neural tube defects.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.)

Reposition the client. Provide oxygen via face mask. Increase IV fluid. Call the healthcare provider.

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose?

Screen for neural tube defects.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?

Skin color that is slightly jaundiced Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn less than 24 hours old

Sperm and Eggs

Sperm lives about 48-72 hours, eggs live about 24 hours. Avoid unprotected sex several days before ovulation and 3 days afterwards.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant.

A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate?

Tachycardia & and a feeling of nervousness

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?

Take your blood pressure now and if it is seriously elevated, go to the hospital. Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?

The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor?

The appearance of the fetal external genitalia

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify her health care provider if she feels fewer than 10 kicks over two, 2-hour intervals or as instructed by her HCP.

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client?

The client's investment in what is being taught Rationale: When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client's particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?

The nurse should evaluate the client for gestational diabetes (A) because terbutaline (Brethine) increases blood glucose levels.

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?

Fetal heart rate (FHR) Rationale: The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best?

"That is normal. The head will return to a round shape within 7 to 10 days."

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client?

"The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan?

"Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

.

Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age.

.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate?

"Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day).

The nurse should include which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth." Rationale: A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

At 30 weeks of gestation Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child.This is closest to the time when parents would be ready for such classes.

Accelerations

Accelerations are caused by burst of sympathetic activity. They are reassuring and require no tx. Early decelerations are caused by HEAD COMPRESSIONS, they are benign and alert the nurse to monitor for labor progress and fetal descent. Variable decelerations are caused by cord compression, change of position should be tried first. Late decelerations are caused by Uteroplacental Insufficiency and should be tx by placing client on her side and administering O2.

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.)

Admission weight of 4 pounds, 15 ounces (2244 grams). Head to heel length of 17 inches (42.5 cm). Frontal occipital circumference of 12.5 inches (31.25 cm).

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?

Allow the cord to air-dry as much as possible. Rationale: Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

At 30-weeks gestation is closest to the time parents would be ready for such classes. Learning is facilitated by an interested pupil! The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

Apply cold compresses to both breasts for comfort. The client is experiencing engorgement even though she is bottle-feeding her infant, and cold compresses (A) may help reduce discomfort. Lactation begins about the third day after delivery, so the mother should avoid any breast stimulation,

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?

Apply firm pressure to sacral area. The discomfort of back labor can be minimized by the application of firm pressure to the sacral area

Late Decelerations

Are caused by uteroplacental insufficiency and require nursing interventions which include changing maternal position, increasing IV fluids, discontinuing oxytocin, administering 8 to 10 L of oxygen via facemask, and delivering the newborn in fetal heart rate pattern is persistent and does not respond resuscitative measures. While this client needs to be assessed, this is not the charge nurses priority. The client with prolonged decelerations has priority.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?

Ask the client if she has felt any fetal movement.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response?

Asking the client and her partner if they would like the nurse to stay in the room

The nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply: wear a supportive bra; rest during the acute phase; maintain a fluid intake of at least 3000 mL; continue to breast feed if the breasts are not too sore; take the prescribed antibiotics until the soreness subsides; avoid decompression of the breasts by breastfeeding or breast pump

wear a supportive bra; rest during acute phase; maintain a fluid intake of at least 3000 mL; continue to breastfeed if breasts aren't too sore