NCLEX Focus on Maternity Exam
A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder?
"Do you have sharp pain on the right or left side of your pelvis?" Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to growth of the dominant follicle within the ovary or to rupture of a follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain, which is fairly sharp, is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days, and slight (not profuse) vaginal bleeding may accompany the discomfort. The pain is not associated with intercourse.
A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures?
"I need to drink at least 2000 mL of fluid a day." Urinary frequency is present in the first trimester and late in the third trimester because of the pressure exerted on the bladder by the enlarging uterus. Self-care measures for urinary frequency include frequent emptying of the bladder (every 2 hours) and drinking at least 2000 mL of fluid a day. Restricting fluid intake at any time is incorrect; it could lead to urinary stasis and fluid-volume deficit
A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction?
"I need to stay in bed for the rest of my pregnancy." Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding, as recommended by the health care provider or nurse-midwife. The woman is instructed to count the perineal pads she uses each day and to note the quantity and color of blood on each pad. The woman should also watch for the evidence of the passage of tissue.
A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for further instruction?
"I should bathe him after a feeding." It is not advisable to bathe a newborn infant after a feeding, because handling the infant may cause regurgitation. Controlling heat loss during the bath to help conserve the infant's energy and prevent cold stress is a priority, and the baby should be covered as much as possible during bathing. The baby should be given sponge bath until the cord falls off. Additionally, the mother should check the temperature of the water before using it to bathe the infant as a means of preventing burns.
A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears?
"Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today." Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis after delivery. Appropriate antenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up with repeat urine cultures. The correct option is the only therapeutic response and is the response that presents accurate information.
A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device?
12 weeks Fetal heart sounds can be heard with the use of a Doppler ultrasound stethoscope by 12 weeks of gestation and can be heard with a fetoscope by 18 to 20 weeks of gestation. The gestational times of 4, 6, and 8 weeks are incorrect because the fetal heart sounds cannot be heard with a Doppler ultrasound stethoscope this early in pregnancy.
A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as:
14 to 16 weeks of gestation The first recognition of fetal movements by the multigravida may occur as early as the 14th to 16th week of gestation. The primigravida may not notice these sensations until week 18 or later. Therefore the other options are incorrect.
A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see?
20 cm During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman's bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present.
A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal?
50 breaths/min The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the normal range.
A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)?
A client with septicemia. A client who had a cesarean section because of abruptio placentae. DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage .A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC.
A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant?
A copper-colored rash Signs of congenital neonatal syphilis — including poor feeding, slight hyperthermia, and "snuffles" (copious clear serosanguinous mucous discharge from the nose) — may be nonspecific at first. By the end of the first week, however, a copper-colored maculopapular dermal rash is characteristically observed on the palms and soles, in the diaper area, and around the mouth and anus. Diarrhea is not specifically associated with this condition.
A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis?
Administering oxygen as prescribed Oxygen is administered continuously during labor to the client with sickle cell anemia to help ensure adequate oxygenation and prevent sickling. Maintaining asepsis, monitoring vital signs, and placing a wedge under the hip are interventions required of all clients, with or without sickle cell anemia. Although they are appropriate nursing interventions, they are not used to prevent sickling crisis.
A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. Based on this finding, which nursing action is the priority?
Administering oxygen by way of face mask Late decelerations are a result of uteroplacental insufficiency stemming from decreased blood flow and oxygen transfer to the fetus during uterine contractions. This causes hypoxemia; therefore oxygen is necessary, making the administration of oxygen the correct choice. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia, because the medication stimulates contractions, leading to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority action in this situation.
A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately:
Administers oxygen to the woman Supportive interventions are instituted immediately to maintain cardiac and respiratory function, and oxygen is a necessary supportive therapy. The woman is intubated, and positive end expiratory pressure (PEEP) may be prescribed. The family should be notified; however, the nurse would first administer the oxygen, then prepare for intubation. A cardiac monitor may be needed, but this is not the initial action.
A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure monitor that the woman's pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing:
Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome) In a pregnant woman, the supine position adds gravity pressure to the inferior vena cava, which is already displaced and partially compressed by the full-term gravid uterus. The increased compression decreases cardiac output, leading to beginning tissue hypoxia, which brings on the signs and symptoms described in the question. The signs and symptoms identified in the question are not indicative of progression to active first-stage labor. There is no information in the question to indicate that the client is experiencing hyperventilation or anxiety.
A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that:
Alternating contraction and relaxation of the muscles of the perineal area should be practiced Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area) are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later, experiencing continued urinary continence.
A nurse is assisting a health care provider in performing a physical examination of a client who has just been told that she is pregnant. The health care provider tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of:
An increase in vascularity and hyptertrophy of the cervix In the early weeks of pregnancy, the cervix becomes more vascular and slightly hypertrophic; this is referred to as the Goodell sign. The edematous appearance of the cervix will be noted during pelvic examination by the examiner. hCG is noted in maternal urine in a urine pregnancy test. The Goodell sign does not indicate the presence of fetal movement or a risk for spontaneous abortion.
A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to:
Apply oil to the affected area on the infant's scalp Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation.
A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn?
Bowel sounds heard over the chest Clinical manifestations associated with CDH include diminished or an absence of breath sounds on the affected side, bowel sounds heard over the chest, cardiac sounds heard on the right side of the chest, and respiratory distress, including dyspnea, cyanosis, nasal flaring, tachypnea, retractions, and a scaphoid abdomen, that develops soon after birth. The presence of excessive oral secretions is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Hiccups and spitting up after meals are clinical manifestations of gastroesophageal reflux. A hiatal hernia may be evidenced by coughing, wheezing, and short periods of apnea.
A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate?
C Accelerations, shown in the correct answer, are brief temporary increases in the fetal heart rate of at least 15 beats/min from baseline and lasting at least 15 seconds. They are an indication of fetal well-being and an oxygenated fetal central nervous system. Variable decelerations do not have the uniform appearance of early or late decelerations. Early decelerations are decreases in the fetal heart rate to below baseline; late decelerations look similar to early decelerations but begin well after the contraction begins and return to baseline after the contraction ends.
A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of:
Calcium gluconate Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid-induced respiratory depression.
A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately:
Check her blood glucose level If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL (3.3 mmol/L), the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz [120 ml]) of unsweetened fruit juice, a half cup (4 oz [120 ml]) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz [240 ml]) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after intake of the carbohydrate. If the glucose level is still below 60 mg/dL (3.3 mmol/L), the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood glucose is tested once again 15 minutes after intake of the carbohydrate, and the health care provider is notified immediately if it is still below 60 mg/dL (3.3 mmol/L), because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention.
A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin stimulation. The nurse determines that the client's behavior may be a result of:
Concern about her own and the baby's well-being Clients have concerns when labor does not proceed as expected and often are worried about the effects of treatments and invasive procedures on themselves and on the fetus. Hypotonic contractions generally occur during the active phase of labor, after a normal latent phase. These contractions are typically of poor intensity and infrequent; they are not painful but cause a very slow progression of labor. Therefore the high level of pain, inability to rest between contractions, and normal lack of control felt during the transition phase of labor are all incorrect.
A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client?
Contractions that begin in the lower abdomen and back and radiate over the entire abdomen Discomfort and pain associated with true labor contractions typically begin in the lower abdomen and back, then radiate over the entire abdomen. Mild, irregular contractions and a lack of changes in the cervix are findings associated with false labor. A firm uterus is present when contractions occur.
A nurse is caring for a client in precipitous labor. In which position does the nurse place the client?
D Priority nursing care of the woman in precipitous labor includes promotion of fetal oxygenation and maternal comfort. A side-lying (lateral Sims) position enhances placental blood flow and reduces the effects of aortocaval compression. Added benefits of this position are slowing of rapid fetal descent and minimization of perineal tearing. The lateral Sims position also places less stress on the perineum. Because the upper leg is supported, the perineum can be better visualized as well. The other options are not the most optimal positions.
A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of:
Diminished edema and vasoconstriction in the brain and kidneys In this client, diuresis is a positive sign, indicating that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects increased tissue perfusion in the kidneys. Clients with severe preeclampsia are not considered out of danger until birth and diuresis have taken place. Diuresis is not an indication of impending seizures. Although renal failure is a complication of severe preeclampsia, it is not the high-output type of failure. Potassium is lost through the urine; therefore hyperkalemia is not associated with diuresis.
A nurse assessing a pregnant client's deep tendon reflexes notes a reflex of 2+. The nurse should:
Document the finding. The normal deep tendon reflex response is an extension and upward thrusting of the foot. A 1+ response indicates a diminished response; 2+ indicates normal response; 3+ indicates increased response, brisker than average; and 4 + indicates a very brisk, hyperactive response. The nurse would document the finding. The actions set forth in the remaining options are unnecessary. If the reflexes were 3+ or 4+, the health care provider would be notified, because these findings suggest preeclampsia.
A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse perform in response to this observation?
Documenting the finding Accelerations are transient increases in the fetal heart rate, normally caused by fetal movement or accompanying contractions. Accelerations are a sign of fetal well-being and adequate oxygen reserve. No intervention besides documentation is necessary in this situation.
A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is:
Documenting the findings The labia of a newborn female may be darker in color than the surrounding skin; this is a normal finding, a result of exposure to the mother's hormones before birth. Edema of the labia and a white mucous vaginal discharge are also normal. Therefore the nurse would document the findings. The other options are unnecessary.
A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to:
Eat carbohydrates such as cereals, rice, and pasta Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review measures to ease and prevent nausea and vomiting if you had difficulty with this question.
A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort?
Eat dry crackers every 2 hours to prevent an empty stomach Morning sickness, which is common during the first trimester of pregnancy, is associated with an increased level of human chorionic gonadotropin (hCG) and changes in carbohydrate metabolism. Morning sickness most often occurs when the pregnant woman arises (hence the name), although a few women experience it throughout the day. Self-care measures include eating dry crackers or toast before getting out of bed, eating dry crackers every 2 hours to prevent an empty stomach, eating small frequent meals, avoiding fatty or spicy foods, consuming fluids separately from meals, and rising slowly from a lying or sitting position to help prevent orthostatic hypotension. The client should not eliminate meals.
A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which finding does the nurse tell the mother is an indicator of infection?
Edema at the base of the cord Symptoms of a cord infection include purulent drainage or redness or edema at the base of the cord. If symptoms of infection occur, the mother should be instructed to notify the healthcare provider, because antibiotics are necessary. The cord begins to dry shortly after birth. It turns a brownish black within 2 to 3 days and falls off within 10 to 14 days.
A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat?
Electronic Doppler The fetal heartbeat can be heard with the use of a fetoscope at 18 to 20 weeks' gestation. When an electronic Doppler ultrasound device is used, the fetal heartbeat can be detected as early as 10 weeks' gestation. An adult stethoscope will not adequately produce the fetal heartbeat. A fetal heart monitor is used during labor or in other situations when the fetal heart rate requires continuous monitoring.
A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture?
Fetal bradycardia Maternal tachypnea Maternal complaint of sudden sharp abdominal pain In a complete uterine rupture, the woman may complain of sudden sharp, shooting abdominal pain and may state that she felt like "something gave way." If she is in labor, her contractions will cease and the pain is relieved. In a complete uterine rupture, bleeding will be concealed, and therefore the client will exhibit signs of hypovolemic shock resulting from hemorrhage (hypotension, tachypnea, pallor, and cool, clammy skin). The fetus is the most common indicator of uterine rupture. Such changes in the fetal heart rate as late or variable decelerations, a decrease in baseline variability, or an increase or decrease in rate are commonly exhibited during a rupture. If the placenta separates, the fetal heart rate will be absent and fetal parts may be palpated through the abdomen.
A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to:
Gently massage the breasts during breastfeeding to help empty the breasts Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown.
A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for:
Hemorrhage The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a low-lying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma.
A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity:
In 2 to 4 weeks Usually a woman may engage safely in sexual intercourse during the second to fourth week after childbirth as long as she experiences no discomfort during intercourse. The other options are incorrect. Engaging in intercourse too early in the postpartum course could result in further injury to perineal tissues damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth.
A nurse performing an assessment of a pregnant client is preparing to take the client's blood pressure. The nurse positions the client:
In a sitting position with the arm in a horizontal position at heart level Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client sitting position and the arm supported in a horizontal position at heart level. Supine on the right or left side and lying down with the arm in a horizontal position at heart level are both incorrect and could cause physiological stress that would affect the blood pressure.
A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which laboratory finding causes the nurse to suspect DIC?
Increased fibrin degradation products DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and activated partial thromboplastin times are prolonged, and fibrin degradation products are increased.
A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?
Increased shortness of breath and bilateral crackles in the lungs HIV infection in a pregnant woman may result in both maternal and fetal complications. Fetal compromise may occur as a result of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk for opportunistic infections. Individuals in the later stages of HIV infection are susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The assessment finding in the correct option could be indicative of an opportunistic infection and requires follow-up.
A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first:
Instructs the client to take several deep breaths If the client has been given an epidural opioid, the nurse should monitor the client's respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the health care provider. If the deep breaths fail to increase the oxygen saturation level, the health care provider is notified and may prescribe oxygen.
Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially:
Instructs the mother to push when signs of separation have occurred To assist in the delivery of the placenta, the woman is instructed to push when signs of separation have occurred. If possible, the placenta should be expelled by means of maternal effort during a uterine contraction. Alternate compression and elevation of the fundus plus minimal controlled traction on the umbilical cord may be used to facilitate delivery of the placenta and amniotic membranes.
After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant:
Is adjusting well to extrauterine life One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. A score of 7 to 10 indicates that the infant should have no difficulty adjusting to extrauterine life. A score of 4 to 6 indicates moderate difficulty that may require some resuscitative intervention. A score of 0 to 3 indicates severe distress and the need for vigorous resuscitation.
A nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority?
Monitoring fetal status The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client's partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority.
A neonate is irritable, cries incessantly, and has a temperature of 99.4° F (37.4°C). The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with:
Neonatal abstinence syndrome Neonatal abstinence syndrome is the term given to the group of signs and symptoms associated with drug withdrawal in the neonate. Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation. This hyperactive response and the signs and symptoms of drug withdrawal seem to be most apparent around 1 week of age. Sepsis, hypercalcemia, and intraventricular hemorrhage cause symptoms of CNS depression.
A nonstress test is performed, and the health care provider documents "accelerations lasting less than 15 seconds throughout fetal movement." The nurse interprets these findings as:
Nonreactive A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording.
A nurse is caring for a client receiving an intravenous infusion of oxytocin to stimulate labor. Which finding would prompt the nurse to stop the infusion?
Nonreassuring fetal heart rate pattern The goal of labor augmentation is to achieve three good-quality contractions (of appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. If a nonreassuring fetal heart rate pattern is detected, the oxytocin infusion is stopped. A nonreassuring fetal heart rate pattern is associated with fetal hypoxia.
A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. Based of this observation, what is the appropriate nursing action?
Notifying the health care provider The anterior fontanel, which is diamond shaped, is located on the top of the head. It should be flat and soft. It measures 1 to 4 cm, varying as a result of molding and individual differences. It normally closes by 12 to 18 months of age. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased intracranial pressure. If this is suspected, the health care provider is notified. The other options would delay necessary treatment.
A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. Based this finding, which nursing action is appropriate initially?
Notifying the health care provider. Low or oddly placed ears are associated with a variety of congenital defects, including Down syndrome, and should be reported immediately. Taping the ears and covering them with gauze are unacceptable nursing interventions. Although the finding would be documented, the appropriate initial action is notification of the health care provider.
A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located:
Outside the abdominal cavity and not covered with a sac Gastroschisis is the herniation of the bowel through a defect in the abdominal wall to the right of the umbilical cord. The bowel is located outside the abdominal cavity and is not covered with a sac. Inside the abdominal cavity, under the dermis or skin, is the description of an umbilical hernia. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane is the description of an omphalocele.
A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to:
Perform Kegel exercises in 10 repetitions, three times per day Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is beneficial during pregnancy and afterward. Walking is a general healthy measure but does not specifically strengthen the pelvic floor. Fluid intake is an indicator of hydration, which is important for normal physiological function. Pelvic tilt exercises ease backache.
A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement?
Performing a sudden tap on the cervix Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position, a phenomenon known as ballottement. The examiner feels the rebound when the fetus falls back down. Ballottement has no relationship to cervical assessment findings, fetal heart sounds, or external palpation of fetal movement.
A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is:
Preparing the client for a cesarean delivery Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need for cesarean delivery. Induction of labor is not indicated in this case because the client has been in labor for 12 hours without progress and signs of fetal distress are present. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. However, this intervention would be implemented with any client in labor, not specifically with a client experiencing dystocia. Monitoring the fetal heart rate pattern is also appropriate for any client in labor and is not the appropriate nursing action in this situation.
A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which situation would the nurse suspect based on this observation?
Pressure on the fetal head during a contraction Early decelerations, which result from pressure on the fetal head during a contraction, are not associated with fetal compromise and require no intervention. Variable decelerations suggest umbilical cord compression. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. "Short-term variability" refers to the difference between successive heartbeats, indicating that the natural pacemaker activity of the fetal heart is working properly.
A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F (37.8° C), and the client reports that she last ate 2 hours ago. The client also states that "everything happened so fast" and that she has had no preparation for the cesarean delivery. Which action should the nurse take first?
Reporting the time of last food intake to the health care provider The nurse should report the time of last food intake to the health care provider. General anesthesia may be used for an emergency cesarean delivery. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Continued monitoring and client instruction are correct nursing actions but are of lesser priority than reporting the time of last oral intake. Giving acetaminophen is incorrect because it requires a health care provider's prescription.
A nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which finding would prompt the nurse to contact the health care provider?
Respirations of 10 breaths/min Magnesium sulfate depresses the respiratory rate. If the rate is 12 breaths/min or slower, continuation of the medication must be reassessed. Acceptable urine output is 30 mL/hr or more. Urine output of 20 mL in 30 minutes is adequate. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus.
A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse:
Simultaneously provides pressure over the lower uterine segment After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion.
A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the health care provider?
Strong-smelling amniotic fluid Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38° C or 100.4° F), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor.
A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective?
The client experiences diuresis within 24 to 48 hours. Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client's lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent.
After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which conclusion should the nurse make?
The client is experiencing low self-esteem. Situational-low self-esteem represents temporary negative feelings about self in response to an event. This is a normal response to cesarean section. Anger is commonly a response to a lack of information or the ability to perform psychomotor skills in connection with a condition or treatment. When a person is unable to manage stressors adequately, the emotional condition is usually one of hopelessness and helplessness. Extreme discomfort is usually evidenced by writhing, moaning, screaming, or total withdrawal. The condition described in the question is not one of extreme discomfort. The information provided in the question best supports the conclusion stated in the correct option.
A nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted in the infant, would indicate that the criteria for early discharge have been met?
The infant has urinated. The infant has passed 1 stool. Vital signs are documented as normal. Criteria for early discharge in the newborn infant include no evidence of significant jaundice in the 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours.
A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that:
The mother may need to take isoniazid, pyrazinamide, and rifampin (Rifadin) for a total of 9 months More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother's sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital.
A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately:
Turn the client on her side With a client in shock, the goal is to increase perfusion to the placenta. The immediate nursing action would be to turn the client on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The remaining options are also interventions that would be implemented, but only after this immediate action had been taken. Additionally, oxygen at 8 to 10 L/min by way of face mask would be administered.
Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which finding would the nurse expect to note?
Uterine tender to palpation Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium, causing uterine irritability and maternal tenderness. A normal uterine contraction pattern is unusual in the presence of a placental abruption. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.
A nurse is monitoring a fetal heart rate (FHR). The nurse documents a reassuring FHR pattern in the record on noting:
Variability of 6 to 25 beats/min Variability of 6 to 25 beats/min is a reassuring pattern. The FHR should accelerate with fetal activity. The baseline range for the FHR is 110 to 160 beats/min. Late decelerations are a result of decreased uteroplacental perfusion that causes a decrease in fetal oxygenation. Late decelerations are not a reassuring pattern.
A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae?
A hypertensive client A pack-a-day smoker The cause of abruptio placentae is unknown, but several risk factors have been identified. Maternal use of cocaine, which causes vasoconstriction of the endometrial arteries, is a leading cause. Other risk factors include hypertension, cigarette smoking, abdominal trauma, and a history of previous premature separation of the placenta.
A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data as:
A normal finding The anterior fontanel, which is diamond shaped, is located on the top of the head. It measures 1 to 4 cm but varies because of molding and individual differences. It normally closes by 12 to 18 months of age. It may be described as soft, which is normal, or full and bulging, which may be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.
A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?
Apple and whole-grain toast The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition.
A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of:
Anxiety and the need for support Any of the situations identified in the options could contribute to the client's behavior, but the most likely reason is anxiety. Anxiety is the only emotion that supports the information identified in the question. The client may be anxious about the unknown effects of complications and want the presence of a support person while she deals with the crisis. There is no information in the question to support the other options.
Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history. Which finding is a contraindication to administration of the medication?
A previous hypersensitivity reaction to immune globulin One contraindication to the administration of Rho(D) immune globulin is previous hypersensitivity to immune globulin. Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way, including amniocentesis. The other options are all indications for administering RhoGam.
A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions:
Are a common occurrence of pregnancy Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions are a normal finding experienced by many pregnant women during pregnancy, the other options represent inaccurate assumptions and an unnecessary intervention.
A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first:
Ask the client to empty her bladder In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman's comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones. Counting the fetal heart rate is not associated with Leopold maneuvers.
A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is:
At zero station Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line.
A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is:
Contacting the health care provider Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the health care provider must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client's response, but, of the options provided, contacting the health care provider is the most appropriate.
A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time?
Dark-red lochia rubra When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14.
A nurse assists the health care provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy?
Determining the fetal heart rate Noting the quantity, color, and odor of the amniotic fluid Taking the client's temperature, pulse, and blood pressure Replacing soiled underpads from beneath the client's buttocks Planning evaluation of the client for signs and symptoms of infection After amniotomy, the fetal heart rate is assessed for at least 1 full minute for changes associated with prolapse or compression of the umbilical cord and the characteristics of the fluid are noted as an indicator of fetal risk. After the fluid has been assessed, the next concern is evaluation of the maternal vital signs. The client's comfort (i.e., the soiled underpads) is considered next. With the ruptured membranes comes an increased risk for maternal infection. For this reason, the client is frequently assessed for signs and symptoms of infection throughout the course of labor.
During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb (4.5 kg) during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't eat regular meals." The appropriate response is:
"Let's make a list of what you're eating." It is important for the nurse to obtain additional information from the client. The nurse is using the therapeutic communication tool of validation and clarification to obtain more information about the client's diet. The other options will block communication. The statement regarding harm to the baby devalues the client and shows disapproval. Informing the health care provider is avoiding the issue, and telling the client that it is all right to gain weight provides false reassurance.
A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is:
"The newborn does have a risk of contracting the infection." An infant born to an HIV-positive mother is at risk for contracting the infection. The modes of transmission are sexual, parenteral, and perinatal. Characteristically the newborn is asymptomatic at birth, but signs and symptoms in an infected child usually become obvious during the first year of life. Therefore the remaining options are incorrect.
A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that:
A rubella vaccine must be administered after childbirth A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist.
A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL (8.6 mmol/L). The nurse tells the client that:
Additional tests will likely be performed to confirm gestational diabetes A maternal 1-hour blood glucose test may be prescribed as a screen for gestational diabetes. If it is increased (140 mg/dL [7.8 mmol/L] or greater), a 3-hour glucose-tolerance test may be recommended to confirm the presence of gestational diabetes. Oral hypoglycemics and insulin would not be prescribed solely on the basis of an increased maternal 1-hour glucose level. Additionally, oral hypoglycemic agents are contraindicated during pregnancy. A result of less than 140 mg/dL (7.8 mmol/L) indicates no need for further glucose testing and continued routine prenatal care.
After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to:
Assist in repositioning the uterus through the vagina into a normal position Uterine inversion occurs when the uterus turns completely or partially inside out, usually during the third stage of labor. The health care provider tries to replace the uterus, by way of the vagina, in a normal position. If this is not possible, laparotomy with replacement is performed. A hysterectomy may be required. Two intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia usually is needed to relax the uterus enough to replace it. To help ensure that the inverted fundus is not trapped in the cervix, oxytocin is not given until the uterus has been repositioned. Fundal massage should be avoided if possible, but, if it is prescribed, it should be conducted very carefully. A Foley catheter may be inserted to keep the bladder empty so that the uterus can contract well, but this is not the immediate action.
A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the health care provider?
Diaphoresis and tachycardia Disseminated intravascular coagulation (DIC) is a complication of preeclampsia. Physical examination reveals unusual bleeding, spontaneous bleeding from the woman's gums or nose, or the presence of petechiae around a blood pressure cuff placed on the woman's arm. Excessive bleeding may occur from a site of slight trauma such as a venipuncture site, an intramuscular or subcutaneous injection site, a nick sustained during shaving of the perineum or abdomen, or injury inflicted during insertion of a urinary catheter. Tachycardia and diaphoresis indicate impending shock as a result of blood loss. Breast enlargement, fetal movement with rest periods, and complaints of feeling hot are all normal occurrences in the last trimester of pregnancy.
A nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which information related by the client would the nurse give the highest priority?
Drinking less than 4 glasses of fluid daily Dehydration will precipitate sickling of the red blood cells in the person with sickle cell disease. Sickling can lead to life-threatening consequences, such as an interruption of blood flow to the respiratory system and placenta, for the pregnant woman and fetus. Therefore a low fluid intake is the priority. Although the client's complaints of poor appetite and occasional dizziness on standing require attention, they are not the priority in this situation. The client's concerns about being able to care for her baby may be a priority after delivery, depending on the specific client situation at the time.
A pregnant client is seen in the clinic for the first time. This is the client's first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction?
"I need to limit my exercise while I'm pregnant." "I'll come back for a prenatal visit every month during my first trimester." Exercise is necessary for the pregnant diabetic client to help maintain control of her diabetes. Concepts related to the timing of exercise, control of food intake, and insulin around the time of exercise should be reviewed with the client. The prenatal visit schedule for clients with a history of diabetes mellitus is more frequent than the normal prenatal course. In the first and second trimesters, prenatal visits should be scheduled every 1 to 2 weeks. The remaining statements are correct, representing important information for the pregnant client with diabetes mellitus.
A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?
"This must be hard for you." Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. "This must be hard for you" is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings.
A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client's vagina. In which order would the nurse perform the following actions?
Assessing the client's fundus Checking the client's vital signs Contacting the health care provider Changing the client's peripads Documenting the findings A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client's fundus. Once it has been determined that the bleeding is not the result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has compromised the client's condition. Next the nurse would contact the health care provider and report the bleeding, fundal height and condition, and vital signs. After contacting the health care provider the nurse would attend to the client's comfort needs, including, in this case, frequent changes of peripads. The nurse would document the findings once assessment and implementation had been completed and the client's condition was considered stable.
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to:
Encourage the intake of oral fluids A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the health care provider or nurse midwife. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids.
A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care?
History of IV drug use AIDS is a breakdown in immune function caused by a retrovirus known as human immunodeficiency virus, or HIV. The infected person contracts opportunistic infections or malignancies that ultimately are fatal. For this reason, the prevention of infection is a priority of nursing care. Although poor hygiene may affect the client's risk for infection, addressing and helping the client cease her use of IV drugs, which is an immediate contributor to the risk for infections, is priority. Inverted nipples and intake of less than 6 glasses of fluid daily are not specifically related to this syndrome.
When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure?
Immediately after delivery Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day.
A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2017. Using Nagele's Rule, the nurse calculates the estimated date of delivery as:
June 26, 2018 Accurate use of Nagele's Rule requires that the woman have a regular 28-day menstrual cycle. It is calculated by subtracting 3 months from the first day of the LMP, adding 7 days, and then adding 1 year to that date. First day of the LMP: September 19, 2017; subtract 3 months: June 19, 2017; add seven days: June 26, 2017; add 1 year: June 26, 2018.
A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid?
Lima beans The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.
A nurse provides instruction regarding prenatal care to a client with a history of heart disease. The nurse tells the client that:
Physical activity should be limited Physical activity should be limited so that demand does not exceed the functional capacity of the heart. It is not necessary to avoid contact with all individuals as a means of preventing infection, but contact with individuals with active infections should be avoided. The client should avoid excessive weight gain, which increases demand on the heart. Too much weight gain causes an increase in body requirements and stress on the heart. The client should lie on the left side to promote blood return.
A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing:
Placenta previa The primary symptom of placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Findings of abruptio placentae include dark-red vaginal bleeding and abdominal pain. A ruptured amniotic sac is characterized by findings such as watery vaginal drainage. Passage of the mucus plug is manifested as pink or as blood-tinged mucus.
A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician's office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately:
Positions the client on her side Supine hypotension may occur during the second and third trimesters when a woman is placed in the lithotomy position, in which the weight of the abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure and a feeling of faintness. Other signs and symptoms include pallor, dizziness, breathlessness, tachycardia, nausea, clammy (damp, cool) skin, and sweating. The nurse would immediately position the woman on her side. Placing a cool washcloth on the client's forehead or checking the client's vital signs will not eliminate this problem. The health care provider must be contacted if the symptoms do not subside, but this would not be the immediate action.
A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?
Prone A myelomeningocele is a neural tube defect caused by failure of the posterior neural tube to close. The meninges are exposed through the surface of the skin in a herniated sac that may be either healed or leaking. One major preoperative intervention is protection of the sac from injury to prevent its rupture and resultant risk of central nervous system infection. The infant should be positioned in a side-lying or prone position to prevent pressure on the sac until surgical repair can be performed. Supine positioning would increase pressure on the sac, thereby increasing the risk for sac rupture.
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. 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 intervention in the care of this client?
Providing pain relief Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes.
A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client:
Supine with a wedge under the right hip The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery.
A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the health care provider will prescribe?
T-lymphocyte determination HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T-lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control. Glomerular filtration rate is an indicator of kidney function. The platelet count is important and may be used as an indicator of the effects of HIV, but the platelet count (thrombocytopenia) has already been addressed in the question.
A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client:
That this is a normal postpartum occurrence For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect.
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that:
The infant should receive both the vaccine and hepatitis immune globulin soon after birth A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive hepatitis immune globulin and a vaccine soon after birth. Repeating the screen and prescribing liver function tests are incorrect measures and are unnecessary.
