PP Antepartum
A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond? "Why don't we discuss this with you at a later time when you're feeling better." "You must wait at least 1 year before becoming pregnant again." "Let me check with your physician and get you something that will help you relax." "Pregnancy should be avoided until all of your testing is normal."
"You must wait at least 1 year before becoming pregnant again." Explanation: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 1 year by an experienced health care provider. Discussing this situation at a later time or checking with the physician to give the client something to relax does nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is a vague response and provides the client with little information.
A woman who has preeclampsia is receiving magnesium sulfate 20 g per 500 mL of lactated Ringer's solution via an infusion pump. The prescribed rate of infusion is 2 g per hour. How many milliliters per hour should the nurse set the infusion pump for? Record your answer using a whole number.
50 Explanation: X = 500mL/20grams x 2grams/hour. X = 50 mL/hour.
A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. What should the nurse tell the client that the test results indicate? A contraction stress test is necessary. The nonstress test should be repeated. Chorionic villus sampling is necessary. There is evidence of fetal well-being.
There is evidence of fetal well-being. The nonstress test is considered reactive when two or more fetal heart rate accelerations of at least 15 bpm occur (from a baseline fetal heart rate of 120 to 160 bpm), along with fetal movement, during a 10- to 20-minute period. A reactive nonstress test indicates fetal heart rate accelerations and well-being. There is no indication for further evaluation (such as a contraction stress test). However, contraction stress tests are commonly scheduled for pregnant clients with insulin-dependent diabetes in the latter part of pregnancy and are repeated periodically until birth. Chorionic villus sampling is usually performed early in the pregnancy to detect fetal abnormalities.
A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note that which symptom should be reported immediately? hemorrhoids blurred vision dyspnea on exertion increased vaginal mucus
blurred vision During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they do not require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.
When performing Leopold maneuvers, the nurse would ask the client to perform which action to ensure optimal comfort and accuracy? breathing deeply for 1 minute emptying their bladder drinking a full glass of water lying on the left side
emptying their bladder Leopold maneuvers involve abdominal palpation. The client should empty their bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly.
A client in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history, what should the nurse suspect? abruptio placentae preterm labor placenta previa threatened abortion
placenta previa Explanation: Placenta previa is associated with painless vaginal bleeding that occurs when the placenta or a portion of the placenta covers the cervical os. In abruptio placentae, the placenta tears away from the wall of the uterus before birth; the client usually has pain and a boardlike uterus. Preterm labor is associated with contractions and shouldn't involve bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks' gestation.
Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision? assessing vital signs and managing pain providing for dietary needs and nursing in a dark quiet room managing pain and providing emotional support providing emotional support and assessing per vaginal loss
providing for dietary needs and nursing in a dark quiet room Explanation: Providing for the client's dietary needs is not appropriate because the client should not eat or drink anything pending surgery. Nursing the client in a dark quiet room is not appropriate for a client with ectopic pregnancy. Assessing vital signs for indicators of potential shock, managing pain, assessing per vaginal loss, and providing emotional support are essential nursing interventions in caring for a client with an ectopic pregnancy.
A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. The client tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: a neurologic disorder. inadequate nutrition. an unknown cause. hemolysis of fetal red blood cells (RBCs).
an unknown cause. Explanation: The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.
A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. The client tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: a neurologic disorder. inadequate nutrition. an unknown cause. hemolysis of fetal red blood cells (RBCs).
an unknown cause. The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.
A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? presence of menses uterine enlargement breast sensitivity fetal heart tones
breast sensitivity Explanation: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea, not the presence of menses, is expected during this time. Uterine enlargement and fetal heart tones don't occur until after the first 4 weeks of pregnancy.
A client who is 10 weeks pregnant develops spotting; however, the cervix remains closed. What should the nurse should suspect? threatened abortion inevitable abortion ectopic pregnancy missed abortion
threatened abortion Explanation: Spotting in the first trimester may indicate that the pregnancy is in jeopardy. Bed rest and avoidance of physical and emotional stress are recommended. Abortion is usually inevitable if the bleeding is accompanied by pain with dilation and effacement of the cervix. An inevitable abortion is associated with cervical dilation. An ectopic pregnancy is in the fallopian tubes, and a false positive pregnancy could reflect a missed abortion.
A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color? Pink Blue Yellow Green
Blue Explanation: Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink.
Which instruction should a nurse include in a home-safety teaching plan for a pregnant client? Place a nonskid mat on the floor of the tub or shower. It's OK to clean your cat's litter box. It's OK to wear high heels. Avoid having area rugs around your house.
Place a nonskid mat on the floor of the tub or shower. Using a mat for the floor of the shower or tub will prevent slipping. The client shouldn't clean the cat's litter box because doing so puts her at risk for toxoplasmosis. Wearing high heels may make the client lose balance and fall. The client doesn't need to completely avoid having area rugs around the house. Nonslip rugs can be used to prevent tripping or falling.
A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask which question? "Have you ever had osteomyelitis?" "Do you have any cats at home?" "Do you have any birds at home?" "Have you recently had a rubeola vaccination?"
"Do you have any cats at home?" Explanation: TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus — agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections. Remediation:
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? "Yes, it produces no adverse effects." "No, it can initiate premature uterine contractions." "No, it can promote sodium retention." "No, it can lead to increased absorption of fat-soluble vitamins."
"No, it can initiate premature uterine contractions." Explanation: Castor oil can initiate premature uterine contractions and other adverse effects in pregnant women. Castor oil doesn't promote sodium retention and isn't known to increase absorption of fat-soluble vitamins.
Which medication is considered safe during pregnancy? aspirin magnesium hydroxide insulin oral antidiabetic agents
insulin Explanation: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. The nurse knows that the client understands the management of the disorder when the client says "I will eat five or six small, nutritious meals each day but with mostly carbohydrates for more energy." "I will eat three meals each day but will avoid all simple carbohydrates in my diet." "I will eat five or six small meals each day and have some protein with each meal." "I will eat my evening meal an hour before bedtime so that digestion can occur while I am resting."
"I will eat five or six small meals each day and have some protein with each meal." Digestion of a large meal shunts blood to the gastrointestinal tract, increasing fatigue levels. Clients with this disorder should ingest small, frequent, and nutritious meals five or six times per day. It is not necessary to completely avoid simple carbohydrates. Eating immediately before bedtime can disturb sleep patterns. A pregnant woman with cardiac issues benefits from sound sleep.
A client at 37 weeks gestation is at a prenatal visit and states that she sometimes feels dizzy when lying directly on her back. Which is the nurse's best response? "This is a normal occurrence in the third trimester." "Do you have a family history of cardiac-related illnesses?" "This may be due to the uterus putting pressure on a blood vessel." "This is most likely due to low hemoglobin."
"This may be due to the uterus putting pressure on a blood vessel." During pregnancy, the uterus enlarges, and if the client is lying in a supine position, the uterus may put pressure on the vena cava, causing supine hypotensive syndrome. This pressure on the vena cava causes a decrease in blood flow and a decrease in blood pressure. Often the client will describe symptoms of dizziness, pallor, and clamminess. Instruct the client to lie on her left side to avoid this type of episode. This is not a normal occurrence, but rather a common experience, given the client's description, and warrants discussion. It would be inappropriate to assume that this is due to low hemoglobin. Asking the client of any family cardiac history may imply the nurse's assumption of cardiac complication and may not be the most appropriate response given the client's description of what is being experienced.
The nurse is providing prenatal education regarding microorganisms to be avoided during pregnancy. Which of the following statements during the counseling session would indicate to the nurse that the client understands the teaching? "Women can be protected from most perinatal infections with vaccinations." "Women should avoid contact with cats while they are pregnant." "Women should avoid unpasteurized milk and cheese and undercooked meat." "Women should receive prophylactic antibiotics to prevent infection during their first trimester."
"Women should avoid unpasteurized milk and cheese and undercooked meat." Explanation: Listeria and toxoplasmosis in pregnancy is contracted from unpasteurized milk, cheese, raw meat and cat feces (not cats themselves). Manifestations in the newborn may be lethal. There are vaccinations against rubella but not against the many other microorganisms such as cytomegalovirus, group B strep, parvovirus, toxoplasmosis, and listeria. Women identified as group B strep carriers should receive prophylactic antibiotics but only if they are carriers.
A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for: amniocentesis. delivery. sonography. tocolytic therapy.
delivery. Explanation: After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor.
A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that fetal movement can be felt beginning at which time? between 10 and 12 weeks' gestation between 18 and 20 weeks' gestation between 21 and 23 weeks' gestation between 24 and 26 weeks' gestation
between 18 and 20 weeks' gestation Explanation: A primigravid can usually detect fetal movements (quickening) between 18 and 20 weeks' gestation. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.
After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when they say that which hormone is produced by the placenta? estrogen progesterone human chorionic gonadotropin (hCG) testosterone
testosterone Explanation: The placenta does not produce testosterone. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. The hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi.
A client at 36 weeks' gestation is scheduled for a routine ultrasound prior to an amniocentesis. After the nurse teaches the client about the purpose of the ultrasound, which client statement would indicate to the nurse that the client needs further instruction? "The ultrasound will help to locate the placenta." "The ultrasound identifies blood flow through the umbilical cord." "The ultrasound will determine where to insert the needle." "The ultrasound locates a pool of amniotic fluid."
"The ultrasound identifies blood flow through the umbilical cord." Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the health care provider where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.
After determining that a pregnant client is Rh-negative, a physician orders an indirect Coombs' test. The purpose of performing this test with a pregnant client is to: determine the fetal blood Rh factor. determine the maternal blood Rh factor. detect maternal antibodies against fetal Rh-negative factor. detect maternal antibodies against fetal Rh-positive factor.
detect maternal antibodies against fetal Rh-positive factor. Explanation: The indirect Coombs' test measures the number of antibodies against fetal Rh-positive factor in maternal blood. The maternal blood Rh factor is determined before the indirect Coombs' test is done. No maternal antibodies against fetal Rh-negative factor exist.
When teaching a group of pregnant adolescent clients about reproduction and conception, the nurse is correct when stating that fertilization occurs: in the uterus. when the ovum is released. near the fimbriated end. in the first third of the fallopian tube.
in the first third of the fallopian tube. Explanation: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.
A client is undergoing fertility testing, and it has been determined that they are oligo-ovulatory. Which drug would be used to stimulate ovulation in this type of menstrual cycle? medroxyprogesterone clomiphene estrogen progesterone
clomiphene Explanation: The drug clomiphene citrate stimulates the release of gonadotropin-releasing hormone, which causes an increased production of luteinizing hormone and follicle-stimulating hormone. These hormones cause follicle growth in the ovaries. The follicles contain the ovum released at the time of ovulation. Medroxyprogesterone is a form of progesterone that suppresses ovulation and is used as a method of birth control. Estrogen is involved in the reproductive cycle, but it does not directly cause ovulation. Progesterone is the hormone that is present and augmented once pregnancy is established as it relaxes the uterus.
Which client statement indicates a need for additional teaching about self-care during pregnancy? "I should use nonskid pads when I take a shower or bath." "I should avoid using soap on my nipples to prevent drying." "I should sit in a hot tub for 20 minutes to relax after working." "I should avoid douching even if my vaginal secretions increase."
"I should sit in a hot tub for 20 minutes to relax after working." The client needs further instruction when they say it is permissible to sit in a hot tub for 20 minutes to relax after work. Hot tubs and saunas should be avoided, particularly in the first trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and they may fall. The client should avoid using soap on the nipples to prevent the removal of natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk for infection.
A primigravid client at 28 weeks' gestation tells the nurse that they and their spouse wish to drive to visit relatives who live several hours away. Which recommendation by the nurse would be best? "Try to avoid traveling anywhere in the car during your third trimester." "Limit the time you spend in the car to a maximum of 4 to 5 hours." "Taking the trip is okay if you stop every 1 to 2 hours and walk." "Avoid wearing your seat belt in the car to prevent injury to the fetus."
"Taking the trip is okay if you stop every 1 to 2 hours and walk." Explanation: The client traveling by automobile should be advised to take intermittent breaks of 10 to 15 minutes, including walking, every 1 to 2 hours to stimulate the circulation, which becomes sluggish during long periods of sitting. Automobile travel is not contraindicated during pregnancy unless the client develops complications. There is no set maximum number of hours allowed. The pregnant client should always wear a seat belt when traveling by automobile. The client should be aware of the nearest health care facility in the city to which they are traveling.
A multigravid client at 38 weeks' gestation is scheduled to undergo a contraction stress test. What should the nurse include in the explanation as the purpose of this test? evaluation of fetal lung maturity determination of the fetal biophysical profile assessment of fetal ability to tolerate labor determination of fetal response during movements
assessment of fetal ability to tolerate labor Explanation: The purpose of a contraction stress test is to determine fetal response during labor. If late decelerations are noted with the contractions, the test is considered positive or abnormal. Fetal lung maturity is evaluated through amniocentesis to obtain the lecithin-sphingomyelin ratio. The nonstress test is part of the biophysical profile. Determining fetal response during movements is evaluated as part of the nonstress test.
A 26-year-old primigravida visiting the prenatal clinic for their regular visit at 34 weeks' gestation tells the nurse that they take mineral oil for occasional constipation. What should the nurse should instruct the client to do? Take the mineral oil with fruit juice to increase the action of the mineral oil. Avoid taking mineral oil because it interferes with the absorption of fat-soluble vitamins. Take the mineral oil at night to prevent a vitamin C deficiency. Use the mineral oil regularly every week to prevent constipation.
Avoid taking mineral oil because it interferes with the absorption of fat-soluble vitamins. Explanation: Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with the absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed.The use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption.Mineral oil does not lead to vitamin C deficiency in pregnant clients.Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation.
The nurse instructs a primigravid client about the importance of sufficient vitamin A in their diet. The nurse knows that the instructions have been effective when the client indicates that they should include which foods in their diet? buttermilk and cheese strawberries and broccoli egg yolks and squash oranges and tomatoes
egg yolks and squash Explanation: Egg yolks and squash and other yellow vegetables are rich sources of vitamin A. Pregnant women should avoid megadoses of vitamin A because fetal malformations may occur. Buttermilk and cheese are good sources of calcium. Strawberries, broccoli, citrus fruits (such as oranges), and tomatoes are good sources of vitamin C, not vitamin A.
After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which statement? "A total weight gain of approximately 20 lb (9 kg) is recommended." "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."
"Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average." The US National Academy of Medicine and Health Canada both recommend that women gain 25 to 35 lb (11.5 to 14.5 kg) during pregnancy. The pattern of weight gain is as important as the total amount of weight gained. Underweight women and women carrying twins should have a greater weight gain. Typically, women should gain 3.5 lb (1.6 kg) during the first trimester and then 1 lb (0.45 kg) per week during the remainder of the pregnancy (24 weeks) for a total of about 27 to 28 lb (12.2 to 12.7 kg). A weight gain of only 6.6 lb (3 kg) in the second and third trimesters is not normal because the client should be gaining about 1 lb (0.45 kg) per week, or 12 lb (5.4 kg) during the second and third trimesters. Gaining 12 lb (5.4 kg) during each trimester would total 36 lb (16.2 kg), which is slightly more than the recommended weight gain. In addition, nausea and vomiting during the first trimester can contribute to a lack of appetite and smaller weight gain during this trimester.
A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that they have a cold and their nose is stuffy. The client tests negative for COVID-19. The nurse should instruct the client to treat the nasal stuffiness by using which approach? oral antihistamines oral decongestants ice packs to the nasal area saline nose drops
saline nose drops Explanation: Saline nose drops are a natural remedy and can alleviate discomfort.Clients who are pregnant should not take any medications without consulting their health care provider; therefore, oral antihistamines and oral decongestions should be avoided.Ice packs are not helpful in alleviating congestion. Warm moist towels might be helpful.
A 36-year-old primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. Why does the nurse need to assess the client's fundal height? to determine the level of uterine activity to identify the need for increased weight gain to assess the fetal position to estimate the fetal growth
to estimate the fetal growth Assessment of fundal height is a gross estimate of fetal growth. By 20 weeks' gestation, the height of the fundus should be at the level of the umbilicus, after which it should increase 1 cm for each week of gestation until approximately 36 weeks' gestation. A fundal height that is significantly different from that implied by the estimated gestational age warrants further evaluation (e.g., ultrasound examination) because it possibly indicates multiple pregnancy or fetal growth retardation. Fundal height estimation will not determine uterine activity or a need for increased weight gain. Leopold maneuvers will determine fetal position, but are not typically done in the second trimester when the fetus is still freely moving.
A client who is planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. What is the nurse's best response? "You'll need to increase your exercise every day." "You need to gain at least 10 lb in the first trimester." "You'll need to increase your intake of red meat to prevent anemia." "Start taking folic acid, 400 mcg daily until you conceive."
"Start taking folic acid, 400 mcg daily until you conceive." When counseling a client who is planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The recommended dose for folic acid is 400 mcg daily for at least 30 days prior to conception. After conception, it is recommended the dose increase to 800 mcg. For any woman who has had an infant with neural tube defects, the dosage is 4,000 mcg for the next pregnancy. Practicing good health habits is an important topic to discuss with all clients, not just pregnant clients. If the woman is participating in an exercise routine, it is safe to continue. Starting a new exercise program is not recommended, nor is it required to exercise every day. Telling the client to gain 10 lb during the first trimester is inaccurate, as is stating that more red meat is required to prevent anemia.
A 32-year-old female client visits the family planning clinic and requests an intrauterine device for contraception. When the nurse is assessing the client, a history of which problem would be most important to determine? thrombophlebitis pelvic inflammatory disease previous liver disease coronary artery disease
pelvic inflammatory disease Explanation: The nurse should assess the client for a history of pelvic inflammatory disease (PID) because intrauterine devices have been associated with an increased risk for PID and perforation of the uterus.A history of thrombophlebitis, liver disease, or cardiovascular disease would be important to assess if the client were to receive oral contraceptives. Thrombophlebitis is a contraindication for oral contraceptives.
An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that they think they are pregnant but don't know what to do. Which nursing intervention is most appropriate at this time? Ask the client about the type of things that they had thought of doing. Give the client some ideas about what to expect will happen next. Recommend a pregnancy test after acknowledging the client's distress. Question the client about their feelings and possible parental reactions.
Recommend a pregnancy test after acknowledging the client's distress. Explanation: Before any interventions can occur, knowing whether the client is pregnant is crucial in formulating a plan of care. Asking the client about what things they had thought about doing, giving the client some ideas about what to expect next, and questioning the client about their feelings and possible parental reactions would be appropriate after it is determined that the client is pregnant.
Following an eclamptic seizure, the nurse should assess the client for which complication? polyuria facial flushing hypotension uterine contractions
uterine contractions Explanation: After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.
A nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching? "I'll need to lie perfectly still." "You won't need to come in and check on me while I'm wearing this monitor." "I can lie in any comfortable position, but I should stay off my back." "I know that the external monitor increases my risk of a uterine infection."
"I can lie in any comfortable position, but I should stay off my back." Explanation: The client demonstrates understanding of the nurse's teaching when she states that she should stay off her back. A woman with an external monitor should lie in the position that is most comfortable to her, but the supine position should be discouraged. It isn't necessary for the client to lie perfectly still. The client should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.
A 16-year-old unmarried client visiting the prenatal clinic at 32 weeks' gestation and currently weighing 140 lb (63.5 kg) is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inches (158 cm) tall and weighed 120 lb (54.4 kg) before the pregnancy. Which factor would be most important to assess? proteinuria small-for-gestational-age fetus ABO incompatibility fluid intake
proteinuria Explanation: Because the client is being closely monitored for early signs of preeclampsia, checking the urine for proteinuria is most important. Proteinuria, even in the absence of elevated blood pressure, is indicative of preeclampsia.Although adolescent pregnancy is associated with an increase in the number of small-for-gestational-age fetuses, this is not indicative of preeclampsia.ABO incompatibility, occurring when the mother has type O blood and the fetus is type A, B, or AB blood, is not associated with preeclampsia.Fluid intake is an important assessment for any pregnant client. However, it is not a primary indication of preeclampsia. Edema of the hands and face is a more important indicator than fluid intake.
During the first trimester, a nurse evaluates a pregnant client for factors that suggest that she might abuse a child. Which parental characteristic is of most concern to the nurse? The client works 60 hours per week. The client states she is stupid and ugly. The client is carrying twins. The client is unmarried and lives with relatives.
The client states she is stupid and ugly. One of the signs indicating the potential for abuse is the parent who has low self-esteem. This parent generally has many unmet needs. A high risk for abuse is present if the parent was abused or neglected as a child. Other factors include substance abuse, young age of the parent, low education level, and single parenthood. Potential abuse risks are higher when there are nonbiological transient caregivers in the home. Living with relatives can offer support to the single parent and ease the burden of caregiving. The number of hours the woman works is not a contributing factor; the workplace could include adequate daycare and support. Multiple births are not a factor for potential abuse.
The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question? autonomy justice nonmaleficence jurisprudence
autonomy Explanation: The principle of autonomy informs decisions when conflicts arise between maternal and fetal rights. The woman has the right to choose for herself what she believes to be in her best interest versus the well-being of the fetus. This is the concept of self-determination, of being in charge of one's person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with her belief system. Jurisprudence is the actual theory or study of law.
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? labor techniques danger signs during pregnancy signs and symptoms of pregnancy tests to evaluate for high-risk pregnancy
danger signs during pregnancy Explanation: No matter how far the client's pregnancy has progressed by the time of the first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they're expected to occur. For example, the nurse should teach about labor techniques near the end of pregnancy; signs and symptoms of pregnancy shortly before they're anticipated, based on the number of weeks' gestation; and any tests a few weeks before they're scheduled.
A client makes a routine visit to the prenatal clinic. Although the client is 14 weeks pregnant, the size of her uterus approximates an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: an empty gestational sac. grapelike clusters. a severely malformed fetus. an extrauterine pregnancy.
grapelike clusters. Explanation: In a client with gestational trophoblastic disease, an ultrasound performed after the third month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy occurs with an ectopic pregnancy.
A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of their previous pregnancies tells the nurse that they have already felt the baby move. How does the nurse interpret this finding? the possibility that the client is carrying twins unusual because most multiparous clients do not experience quickening until 30 weeks' gestation evidence that the client's estimated date of birth is probably off by a few weeks normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation
normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation Explanation: Although most multiparous women experience quickening at about 17½ weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect. Detecting movement early does not suggest a twin pregnancy. If the multiparous client does not experience quickening by 20 weeks' gestation, further investigation is warranted, because the fetus may have died, the client may have a hydatidiform mole, or the pregnancy dating is incorrect. There is no evidence that the client's expected date of birth is erroneous.
A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings may signify: infection. umbilical cord prolapse. start of the second stage of labor. need for labor induction.
umbilical cord prolapse. Explanation: After an amniotomy, a significant change in the FHR, particularly large variable decelerations associated with cord compression, may indicate umbilical cord prolapse. This movement of the umbilical cord relative to the fetal presenting part is an obstetric emergency that requires immediate intervention to prevent fetal hypoxia. Infection, the start of the second stage of labor, and the need for labor induction aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.
A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of their previous pregnancies tells the nurse that they have already felt the baby move. How does the nurse interpret this finding? The possibility that the client is carrying twins Unusual because most multiparous clients do not experience quickening until 30 weeks' gestation Evidence that the client's estimated date of birth is probably off by a few weeks Normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation
normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation Although most multiparous women experience quickening at about 17½ weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect. Detecting movement early does not suggest a twin pregnancy. If the multiparous client does not experience quickening by 20 weeks' gestation, further investigation is warranted, because the fetus may have died, the client may have a hydatidiform mole, or the pregnancy dating is incorrect. There is no evidence that the client's expected date of birth is erroneous.
A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse to say they have had a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. What should the nurse should tell the client? "Take two acetaminophen tablets. They are not as likely to upset your stomach." "I think the health care provider (HCP) should see you today. Can you come to the clinic this morning?" "You need to lie down and rest. Have you tried placing a cool compress over your head?" "I will ask the HCP to call in a prescription for nausea medications. What is your pharmacy's number?"
"I think the health care provider (HCP) should see you today. Can you come to the clinic this morning?" A client with preeclampsia and a continuous headache for 2 days should be seen by an HCP immediately. Continuous headache, drowsiness, and mental confusion indicate poor cerebral perfusion and are symptoms of severe preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Treatment for nausea may be indicated, but only after the primary HCP has seen the client and determined if the preeclampsia requires further treatment.
The public health nurse is teaching a prenatal class about tobacco smoke during pregnancy. Which comment made by one of the class members demonstrates that the teaching was effective? "My newborn will be more relaxed if I smoke during pregnancy." "My newborn is more at risk for heart problems if I smoke during pregnancy." "If I continue to smoke during pregnancy, my baby could be born small." "Smoking during pregnancy increases the risk of having a cesarean section."
"If I continue to smoke during pregnancy, my baby could be born small." Explanation: Smoking exposure during pregnancy increases the risk of intrauterine growth restriction or a small baby. Smoking exposure during pregnancy also increases the risk of the newborn being more irritable but does not increase the risk for congenital heart problems or the risk of a cesarean section.
A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that they have been maintaining a low-sodium, 1800-calorie diet. Which instruction should the nurse give the client? Avoid folic acid supplements to prevent megaloblastic anemia. Severely restrict sodium intake throughout the pregnancy. Take iron supplements with milk to enhance absorption. Increase caloric intake to 2200 calories daily to promote fetal growth.
Increase caloric intake to 2200 calories daily to promote fetal growth. The client can continue a low-sodium diet but should increase the caloric intake to 2200 calories daily to provide adequate nutrients to support fetal growth and development. Folic acid supplements, a standard component of care, are used to prevent folic acid deficiency, which is associated with megaloblastic anemia during pregnancy. Severe restriction of sodium intake is not recommended because sodium is necessary to maintain fluid volume. Iron supplements should be taken with acidic foods and fluids (e.g., citrus juices) for maximum absorption. Milk decreases the absorption of iron.
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take? Place the client on her left side and start supplemental oxygen, as ordered. Administer I.V. oxytocin, as ordered. Ease the client's anxiety by assuring her that everything will be all right. Massage the client's fundus.
Place the client on her left side and start supplemental oxygen, as ordered. Explanation: The client's signs and symptoms indicate abruptio placentae, which decreases fetal oxygenation. To maximize fetal oxygenation, the nurse should place the client on her left side to increase placental blood flow to the fetus and administer supplemental oxygen, as ordered, to increase the blood oxygen level. Administering oxytocin is not appropriate because this drug stimulates contractions, which further reduce fetal oxygenation. The nurse cannot assure the client that everything will be all right, only that everything possible will be done to help her and her fetus. Fundal massage is used only during the postpartum period to control hemorrhage.
A client at 6-weeks' gestation comes to the emergency department, and a transvaginal ultrasound confirms ectopic pregnancy with the tube intact. The client will be treated medically. What medication will the nurse prepare to administer to this client? methotrexate methylergometrine bromocriptine dinoprostone
methotrexate Explanation: An ectopic pregnancy is any pregnancy in which the fertilized ovum implants outside the uterine cavity. As the embryo enlarges, it creates the potential for organ rupture. With early diagnosis, most women with ectopic pregnancy can be treated with an IM injection of methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo. To be eligible for medical treatment, the client must be hemodynamically stable with no active bleeding, the hCG level must be below 5,000 mU/mL, and the mass must measure less than 4 cm. Prostaglandins, misoprostol, and actinomycin have also been shown to be effective in treating an intact ectopic pregnancy. Methylergometrine and dinoprostone stimulate uterine contractions to terminate a pregnancy. Bromocriptine is used to treat menstrual irregularities.
When teaching a primigravid client about the diagnostic tests used in pregnancy, the nurse should include which information? A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Fetal heart rate increases during a nonstress test are an ominous sign and require further evaluation with fetal echocardiography. Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks' gestation. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample.
A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Explanation: The fetal biophysical profile includes fetal breathing movements, fetal body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Normal nonstress test findings include at least two qualifying accelerations in the fetal heart rate from baseline in 20 minutes. A contraction stress test or oxytocin challenge test should be performed only on women who are at risk for fetal distress during labor. The contraction stress test is rarely performed before 28 weeks' gestation because of the possibility of initiating labor. Percutaneous umbilical cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood sample.
Assessment of a client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station, and completely effaced; and fetal heart rate of 136 bpm. What should the nurse plan to do next? Assist the client with comfort measures and breathing techniques. Turn the client from the left side-lying position to the right side-lying position. Prepare the client for epidural anesthesia to relieve pain. Instruct the client that internal fetal monitoring is necessary.
Assist the client with comfort measures and breathing techniques. Explanation: The client's assessment findings indicate that the client is in the latent phase of the first stage of labor. Therefore, the nurse should plan to assist the client with comfort measures and breathing techniques to relieve discomfort. The client can move around, walk, or ambulate at this phase of labor. If the client chooses to remain in bed, a left side-lying position provides the greatest perfusion. It is too early for the client to have an epidural anesthetic. Epidural anesthesia is usually administered when the cervix is dilated 4 to 5 cm. The fetal heart rate is normal, so internal fetal monitoring is not warranted at this time.
A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, "What does that mean?" The nurse explains that a reactive nonstress test indicates which of the following about the fetus? Evidence of some compromise that will require birth soon. Fetal well-being at this point in the pregnancy. Evidence of late decelerations occurring during the test. No accelerations demonstrated within a 20-minute period.
Fetal well-being at this point in the pregnancy. A reactive nonstress test is a positive sign indicating that the fetus is doing well at this point in the pregnancy. For a nonstress test to be a reactive test, at least two accelerations (15 beats or more) of the fetal heart rate lasting at least 15 seconds must occur after movement. If the fetus were compromised, the nonstress test would demonstrate no accelerations in fetal heart rate; a contraction stress test would show fetal heart rate decelerations during simulated labor. Late decelerations are associated with a positive or abnormal contraction stress test. No accelerations in a 20-minute period during a nonstress test may mean that the fetus is sleeping; however, this is interpreted as a nonreactive nonstress test.
A multigravida client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which instruction would be most helpful? Perform slow contraction and relaxation of the feet and ankles twice daily. Take frequent rest periods with the legs elevated above the hips. Avoid support hose that reach above the leg varicosities. Take a leave of absence from work to avoid prolonged standing.
Take frequent rest periods with the legs elevated above the hips. The client with leg varicosities should take frequent rest periods with the legs elevated above the hips to promote venous circulation. The client should avoid constrictive clothing, but support hose that reach above the varicosities may help alleviate the pain. Contracting and relaxing the feet and ankles twice daily is not helpful because it does not promote circulation. Taking a leave of absence from work may not be possible because of economic reasons. The client should try to rest with their legs elevated or walk around for a few minutes every 2 hours while on the job.
A client at 38 weeks gestation with twins is placed on bed rest at home and has a home care nurse visit her on a regular basis. Which recommendation should the nurse suggest to her about her position in bed? The client should lie on her right side as much as possible. The client should lie on her left side as much as possible. The client should lie on her back as much as possible. The client can lie in whichever position is comfortable.
The client should lie on her left side as much as possible. Explanation: Lying in the left lateral recumbent position decreases pressure on the vena cava, increasing venous return, circulatory volume, and placental and renal perfusion. Improved renal blood flow helps decrease angiotensin II levels, promotes diuresis, and lowers blood pressure. While the nurse does want to promote comfort, the client lying on her back may cause the uterus to put pressure on the vena cava, causing supine hypotensive syndrome. This pressure on the vena cava causes a decrease in blood flow and blood pressure. The left side-lying position is the most appropriate response.
The nurse is performing a health history for a client in her first trimester of pregnancy who lives alone with two cats. What education should the nurse provide so that the client can protect herself from illness? The client should apply bleach to her hands after cleaning the litter box. The client should wear disposable gloves to clean the litter box and wash hands with soap and warm water after cat litter exposure. The client should apply protective barrier cream to the hands after coming in contact with cat litter. The client should avoid any exposure to cat litter because she may contract rubella.
The client should wear disposable gloves to clean the litter box and wash hands with soap and warm water after cat litter exposure. Explanation: Toxoplasmosis is contracted primarily through exposure to uncooked meat or through handling cat litter or soil in which cat feces is present. The pregnant mother should be sure to have someone else handle the litter or use a hands free litter box. If exposure is unavoidable, the client should wear disposable gloves and be sure to wash hands with soap and warm water after exposure.
The nurse on the antenatal unit is planning care for four clients. The nurse should assess which client first: a 29-year-old client carrying twins, being treated for preterm labor at 29 weeks' gestation and receiving magnesium sulfate at 2 g/h, with stable fetal heart rates and no contractions for the past 2 hours a 19-year-old 18 weeks' intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle accident with bright red vaginal bleeding a client at 38 weeks' gestation hospitalized frequently during this pregnancy for placenta previa and who two days ago was admitted with severe bright red vaginal bleeding that has tapered off now a 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours
a 19-year-old 18 weeks' intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle accident with bright red vaginal bleeding The client who is 18 weeks with an intrauterine pregnancy (IUP) is not stable with bright red vaginal bleeding. Even with a nonviable fetus, the mother is in jeopardy with continued bleeding. The client who is 9 weeks' IUP and has not vomited for 12 hours appears stable at this point with a nonviable fetus. The client treated for placenta previa also appears stable as her bleeding has tapered off since admission. The 29-week gestation client carrying twins has no information indicating that she is in jeopardy, with no contractions in the past 2 hours, and is becoming more stable.
When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point? halfway between the client's symphysis pubis and umbilicus at about the level of the client's umbilicus between the client's umbilicus and xiphoid process near the client's xiphoid process and compressing the diaphragm
at about the level of the client's umbilicus Explanation: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm per week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid process owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.
A nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? on the day of discharge when the client expresses readiness to learn when the client's vomiting has stopped on admission to the facility
on admission to the facility Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Such factors as when the client stops vomiting and expresses readiness to learn shouldn't influence when the nurse begins discharge planning.
A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission? penicillin G potassium I.V. to the client amoxicillin trihydrate P.O. to the client ceftriaxone I.M. to the neonate immediately after delivery methylprednisolone I.V. to the client
penicillin G potassium I.V. to the client Explanation: Administering penicillin G potassium I.V. before delivery will prevent fetal transmission of group B streptococcus infection. Amoxicillin P.O. isn't effective against chorioamnionitis caused by group B streptococcus. Treatment with penicillin G potassium should begin before delivery to prevent fetal transmission. Steroids, such as methylprednisolone, aren't bactericidal.
A client at 24 weeks' gestation comes to the clinic for a prenatal check-up and reports that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem? gestational diabetes hyperemesis gravidarum preeclampsia placenta previa
preeclampsia Explanation: The visual disturbance and proteinuria suggest hypertension that has progressed to preeclampsia. The client with gestational diabetes would have elevated glucose levels. The client with hyperemesis gravidarum would present with intractable vomiting and signs of dehydration. Placenta previa is the covering of the cervical os with the placenta and would be demonstrated by painless vaginal bleeding.
A 32-year-old multigravida client returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include blood pressure, 140/90 mm Hg; pulse, 80 beats/min; and respiratory rate, 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic? headaches blood glucose level proteinuria peripheral edema
proteinuria Explanation: The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if the client has protein in her urine. If the client does not, they may be having transient hypertension. The peripheral edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. While the preeclamptic client may have significant edema in the face and hands, edema can be caused by other factors and is not part of the diagnostic criteria. Headaches are significant in pregnancy-induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis.
