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a nurse is assessing a client who is at 35w and has preeclampsia w/o severe ft. which of the following findings should the nurse identify as the priority? A. 480 uo in 24 hr B. bp 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine
A. 480 uo in 24 hr min acceptable uo in an adult client is 30 ml/hr -- this can indicate progression of preeclampsia w severe ft which requires immediate intervention (priority)
A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? A. accepting the pregnancy B. preparing for the end of pregnancy C. preparing for parenthood D. accepting the baby
A. accepting the pregnancy accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester preparing for the end of pregnancy is a psychological task that the client is expected to accomplish during the 3rd trimester accepting the baby is a psychological task that the client is expected to accomplish during the 2nd trimester
A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? A. lateral B. lithotomy C. trendelenburg D. prone
A. lateral later/side-lying promotes uteroplacental blood flow and helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness lithotomy position (supine with head lower than pelvis) is still a supine position. supine hypotension results from the pressure of the gravid uterus on the ascending vena cava lying prone is uncomfortable for women who are past the first trimester of pregnancy, and it does not relieve supine hypotension
A nurse is assessing a client at 27 weeks gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. the fundal height measures greater than gestational age B. a rigid abdomen is noted on palpation C. client reports a pain level of 8 on a 1-to 10 pain scale D. urine drug screen is (+) for cocaine
A. the fundal height measures greater than GA clients with placenta previa often measures slightly larger than expected because the fetus remains higher in the uterus
a nurse is providing pp d/c teaching to a client who is non-lactating about breast discomfort relief measures. which of the following pieces of info should the nurse include? A. "wear a loose-fitting bra to alleviate breast discomfort" B. "place fresh cabbage leaves on your breast" C. "apply warm, moist compresses to your breasts" D. "express small amounts of milk from your breasts frequently"
B. "place fresh cabbage leaves on your breasts" after 3 days pp, client's breasts can become swollen and distended bc of congestion of vascular structures of the breasts -- fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. the coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts -- leaves should be replaced when they become wilted patient should be instructed to wear a tight-fitting bra/breast binders to alleviate engorgement and swelling application of warmth to the breasts should be avoided bc heat can stimulate milk production -- ice pack should be used to relieve engorged breasts milk shouldn't be expressed -- this intervention would increase milk production rather than decrease it
a nurse is teaching the guardian of newborn about caring for the newborn's umbilical cord. for which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. they can cause increased pain from the cord B. they can cause delayed cord separation C. they can cause swelling of the surrounding tissue D. they can cause skin discoloration
B. they can cause delayed cord separation no evidence that antimicrobial preparations are of any benefit in the process of the drying/detachment of the umbilical cord stump. keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection tissue of the cord is not longer functioning, therefore, the cord cannot cause the baby pain swelling around the cord is indication of infection. antimicrobial agents would not cause infection, but the provider might prescribe them to treat the infection. most antiseptics are colorless. providine-iodine is an exception, but it would only cause temporary discoloration from the antiseptic, not permanent discoloration of the skin
a nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. send a sample of amniotic fluid to the lab to screen the client for chlamydia B. send a sample of amniotic fluid to the lab to test for an elevated Rh-negative titer C. administer immune globulin to the client to prevent fetal isoimmunization D. administer intravenous abx to prevent infection
C. administer immune globulin to the client to prevent fetal isoimmunization to help ensure maternal antibodies will not form against any placental RBC that may have accidentally been released into the maternal bloodstream during the procedure provider screens the client for chlamydia during a pelvic exam rather than through an amniocentesis testing the client's blood for Rh antibodies is done at the beginning of pregnancy and repeated at 28 weeks -- this dx test performed on the client' blood rather than amniotic fluid provider performs amniocentesis with sterile technique -- although infection is a risk with any invasive procedure, the routine administration of prophylactic abx is not indicated
a nurse is providing teaching for a client about hormonal changes during pregnancy. the nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. oxytocin B. Prolactin C. Progesterone D. Estrogen
C. progesterone progesterone maintains the endometrium and has a relaxant effect on the uterus so that the fetus is not expelled oxytocin stimulates uterine contractions -- responsible for the excretion of milk during lactation prolactin prepares the breasts to synthesize and secrete milk estrogen stimulates uterine contractility and growth of the uterus and breast glandular tissue -- estrogen levels rise near the end of pregnancy to prepare for the onset of labor
A nurse is creating a POC for a client who is in the active stage of labor and expresses a desire to use nonpharm methods of pain relief. Which of the following interventions should the nurse include? A. encourage the client to listen to music B. instruct the client how to use informational biofeedback C. ask the client to reconsider using a regional anesthetic D. assist the client into a warm shower
D. assist the client into a warm shower warm shower method stimulates the release of endorphins and increases circulation -- research supports the use of hydrotherapy as an effective method of labor pain management music can provide distraction/relaxation while a client is in early labor, but evidence does not support the effectiveness of music as a method of pain relief during active labor informational biofeedback can be an effective method of increasing relaxation; however, this method must be taught and practiced during the prenatal period to be effective during labor
A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? A. elevated serum potassium level B. rapid weight gain C. peripheral edema D. presence of ketones in urine
D. presence of ketones in urine nurse should expect a client with hyperemesis gravidarum to have ketonuria d/t an inadequate dietary intake -- resulting in the breakdown of protein and stored fat (hypokalemia d/t inadequate dietary intake) (weight loss d/t n/v/d) (indications of dehydration)
A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of info should the nurse provide for the client regarding the recommended weight gain during pregnancy? A. "you should plan to gain no more than 20 lb during your pregnancy" B. "you should plan to gain between 25 to 35 lb during your pregnancy" C. "you should not plan to gain any weight during your pregnancy because you are already well-nourished" D. "since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 lbs"
a. "you should plan to gain no more than 20 lb during your pregnancy" women who have a BMI above 30 should limit their weight gain to 11-20 lbs during pregnancy. Excessive weight and weight gain increase the risk of complications during and after pregnancy
A nurse is caring for a client who is at 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response? A. "lanugo has disappeared" B. "the fetus resemble a human" C. "the arm and leg buds are noticeable" D. "subcutaneous fat gives the body a wrinkled appearance"
b. "the fetus resembles a human" lanugo covers the body at this fetal age leg and arm buds become noticeable between weeks 5 and 6 a lack of subcutaneous fat make the body appear wrinkly
