PassPoint Antepartum, Management of Care,

A nurse is teaching a pregnant client how to distinguish false labor contractions from true labor contractions. Which statement by the client indicates an understanding of this concept?

"False labor contractions are usually felt in the abdomen." Explanation: False labor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking.

The nurse is preparing a client for an ileostomy. Two weeks before the surgery, what should the nurse instruct the client to do?

Stop taking drugs that will interfere with clotting. Explanation: The nurse should instruct the client to stop taking drugs that would interfere with clotting, such as aspirin or ibuprofen. The client should follow a high-fiber diet with increased fluids during the 2-week preoperative period. It is not necessary to limit fluids. The client does not need to report having a temperature above 99° F (37.2° C) to the health care provider (HCP) as this is within normal limits; however, if the temperature is higher, this could indicate an infection, and the client should notify the HCP.

The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?

a 4-year-old with chronic graft-versus-host disease who is incontinent Explanation: The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.

A pregnant client at 26 weeks gestation walks a moderate distance to get to her prenatal class. When she gets to the class, she starts experiencing uterine cramping with no backache or bloody show. She is quite concerned about the cramping and asks the nurse what is happening. The most appropriate response from the nurse would be to

advise the client to rest and drink fluids. Explanation: Braxton Hicks contractions are irregular, generally painless uterine cramping and occur intermittently throughout the pregnancy often beginning around 16 weeks gestation. The client should rest and drink fluids to alleviate Braxton Hicks contractions. Lightening describes the effects when the fetus settles into the pelvis and cramping is not a sign. The client does not have the symptoms of preterm labor or miscarriage.

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse?

blood pressure of 146/90 mm Hg Explanation: A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus.

During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms?

eustachian tube vascularization Explanation: During pregnancy, increasing levels of estrogen — not progesterone — cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears. The client's symptoms don't suggest a serious neurologic disorder or an ear infection.

A client who is 32 weeks pregnant is hospitalized with preterm labor. After preterm labor is arrested, she is discharged with a prescription for terbutaline. Which instruction should the nurse provide during discharge teaching?

"Abstain from sexual intercourse unless you use a condom." Explanation: A client who's predisposed to preterm labor should abstain from sexual intercourse because semen contains prostaglandins that stimulate uterine contractions. A client receiving terbutaline should return to the clinic in 1 to 2 weeks for a regular checkup and evaluation for preterm labor. Returning to work — especially to a job that involves much standing — is contraindicated immediately after preterm labor. Terbutaline must be taken regularly to prevent recurrence of preterm labor.

A nurse is completing a health screening activity to identify at which point in the menstrual cycle a client's problem occurs. Place the pathophysiologic steps of the menstrual cycle listed below in the correct sequential order. All options must be used.

1. The top layer of the endometrium breaks down and sloughs. 2. The endometrium begins thickening. 3. The level of estrogen in the blood peaks. 4. A follicle matures and ovulation occurs. 5. Peak endometrial thickening occurs. 6. Increased estrogen and progesterone levels inhibit luteinizing hormone. Explanation: The nurse is performing a health screening by reviewing the steps in the menstrual cycle. The menstrual cycle begins with the first day of menstruation, when the top layer of endometrium breaks down and begins to slough off. As the endometrium thickens, the level of estrogen in the blood begins to rise and eventually peaks. The follicle matures and ovulation occurs when estrogen levels peak. After ovulation, the endometrium continues to thicken to its peak level. Increased estrogen and progesterone levels inhibit follicle-stimulating hormone, which causes a feedback loop that then decreases estrogen and progesterone production. This causes the top layer of the endometrium to break down and slough, restarting the cycle in a nonpregnant female.

A client is admitted to the addictions unit for a confirmed and long-term addiction to alprazolam. She continues to strongly deny her addiction, stating she was prescribed the alprazolam to control her "panic attacks." Which procedures would be the most important during the admission process? Select all that apply.

Assess the client for suicide, escape, and aggression risks. With the client present, search the client's clothes and belongings for contraband and restricted items. Initiate withdrawal precautions. Obtain a urine specimen for a urine drug screen. Explanation: Clients who deny an addiction and the need for treatment can be at risk for a suicide attempt, efforts to escape the unit, and aggression directed at staff. A contraband search is a safety measure to look for concealed drugs and dangerous items. Depending on the last use of the substance, withdrawal symptoms can begin quickly. A urine drug screen is crucial to determine what other substances the client may be using that may cause other withdrawal symptoms. Explaining the unit routines and groups can wait until the client is calmer and more receptive.