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A woman comes in for her annual gynecological examination and informs the nurse that she is going to try and become pregnant. She asks the nurse when the best time in the month is to become pregnant. What is the best response by the nurse?
"3 days before until 2 days after ovulation." *Sperm are able to fertilize the ovum for up to 72 hours after ejaculation, and the ovum remains fertile for a maximum of 48 hours after ovulation. Thus, the window of opportunity for conception is 3 days before until 2 days after ovulation.
During the health assessment of a pregnant client who is 30 years old, the nurse discusses preventive breast care. Which recommendation would the nurse include?
"A clinical breast exam can help detect any structural problems that may affect breastfeeding. *Breast self-examination is no longer thought to yield enough reliable information to be continued as a monthly self-care routine, but women should be alerted to normal breast changes during pregnancy and about the responsibility to begin having mammograms when they reach 40-45 years of age. Clinical breast examination in women of average risk has not been shown to be effective at any age. However, it may be helpful in identifying any anatomical issues with breastfeeding that may occur. Confirm whether a woman has had a human papillomavirus (HPV) vaccine, as many women are not yet aware that the vaccine has the potential to not only prevent HPV infections but also prevent cervical cancer; it is not associated with breast cancer, however.
A woman at 15 weeks' gestation who works at a daycare center thinks she may have just been exposed to rubella at work. The client asks how this may affect her fetus. What is the bestresponse the nurse can give?
"By the end of the eighth week all of the organ systems and major structures are present, so exposure to any teratogen can lead to birth defects. More assessments are needed." *All organ systems are complete at 8 weeks gestation. During this time of organogenesis the growing structure is most vulnerable to invasion by teratogens.
A woman who is 8 weeks' pregnant has come to the clinic for an evaluation. During the visit, the woman asks the nurse, "When will I be able to hear my baby's heartbeat?" Which response by the nurse would be most appropriate?
"We will be able to hear it at about 10 weeks with a Doppler." *Fetal heart sounds can be heard and counted as early as the 10th to 11th week of pregnancy using an ultrasound Doppler technique. This is done routinely at every prenatal visit past 10 weeks.
The nurse is counseling a client with a BMI of 23 about weight gain during pregnancy. The nurse teaches the client that during the second and third trimester of pregnancy, dietary intake should be increase by how many calories per day above what she was eating prior to the pregnancy?
300 *A BMI of 23 is considered a healthy weight. For clients at a healthy weight, 300 additional calories are needed to support fetal growth in the second and third trimester of the pregnancy. If the client had been underweight, more calories would have been recommended; if the client had been obese, less calories would have been recommended.
A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function?
Amniotic fluid volume *A biophysical profile combines five parameters (fetal reactivity, fetal breathing movements, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment. The fetal heart and breathing record measures short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.
During a routine antepartal visit, a pregnant woman reports a white, thick vaginal discharge. What would the nurse do next?
Ask the woman if she is having any itching or irritation. *Although vaginal secretions increase during pregnancy, the nurse would need to ascertain if this discharge is the normal leukorrhea of pregnancy or if it is a monilial vaginitis, which is common during pregnancy. The nurse needs additional information to conclude that the woman's report is normal. A culture may or may not be necessary. There is no evidence to suggest that her membranes have ruptured.
During an exam, the nurse notes that the blood pressure of a client at 22 weeks' gestation is lower, and her heart rate is 12 beats per minute higher than at her last visit. How should the nurse interpret these findings?
Both findings are normal at this point of the pregnancy. *A pregnant woman will normally experience a decrease in her blood pressure during the second trimester. An increase in the heart rate of 10 to 15 beats per minute on average is also normal, due to the increased blood volume and increased workload of other organ systems. Hormonal changes cause the blood vessels to dilate, leading to a lowering of blood pressure.
A client at 10 weeks' gestation is complaining of ptyalism over the past 2 weeks. What intervention would the nurse recommend to this client? Select all that apply.
Chew gum. Suck on hard candies *Ptyalism or excess salivation may be relieved by chewing gum or sucking on hard candies. Many of the interventions used to relieve nausea and vomiting may also work for ptyalism.
The nurse is assessing a young female who just found out she is pregnant. She is now reporting vague abdominal discomfort. After noting the client has a history of PID, the nurse predicts the health care provider will give priority to ruling out which situation?
Ectopic pregnancy *An ectopic pregnancy or tubal pregnancy can result when there is blockage or scarring of the fallopian tubes due to infection (PID) or trauma (tubal ligation reversal). Ectopic pregnancy may present with vague signs and symptoms but is the leading cause of maternal death in the first trimester and should be given priority when determining the cause of abdominal complaints. The other choices would be ruled out after the ectopic pregnancy is ruled out.
A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply.
Establish a baseline of present health. Determine the gestational age of the fetus. Monitor for fetal development and maternal well-being. Identify women at risk for complications.
The nurse is performing an assessment of a woman who has come to a health care facility for a diagnosis of pregnancy. The women is positive for breast changes, nausea, and amenorrhea. On physical exam, it is noted that the client has softening of the cervix. How should the nurse document this in her notes?
Goodell sign *The description of a Goodell sign is softening of the cervix. Ballottement is when tapping the lower uterine segment on a bimanual exam elicits the fetus to rise against the abdominal wall. Chadwick sign is when the vagina changes color from pink to violet. Hegar sign is softening of the lower uterine segment.
A client at 16 weeks' gestation comes to the office for a routine exam. At what location within the abdomen would the nurse anticipate the uterus to be found?
Halfway between the symphysis pubis and the umbilicus *As the pregnancy progresses, the uterus enlarges and enters the abdominal cavity. At 16 weeks, the nurse should be able to palpate the uterus halfway between the symphysis pubis and the umbilicus.
The nursing instructor is teaching a class on the structures vital to the development of the fetus. The instructor determines the class is successful when the class correctly chooses which facts concerning amniotic fluid?
Helps the fetus regulate body temperature *Amniotic fluid is formed by the fetal membranes, the amnion and chorion, on a constant basis until birth. It is 98% to 99% water, with the remaining 1% to 2% composed of electrolytes, creatinine, urea, glucose, hormones, fetal cells, lanugo, and vernix. It serves four main functions: physical protection, temperature regulation, provision of unrestricted movement, and symmetrical growth. The fetus is unable to regulate its own body temperature so the amniotic fluid provides this function.
The parents of a neonate born at 32 weeks' gestation ask about the purpose of the surfactant being given to the baby. What is the best response by the nurse?
Helps the lungs remain expanded after the initiation of breathing *Surfactant keeps the alveolar surfaces from sticking together, allowing the lungs to expand and making it easier for the neonate to breathe. Surfactant does not remove mucus or mature the upper airway. It does not effect the breathing pattern, just the effort needed to expand the alveoli.
A student nurse is preparing for a presentation that will illustrate the various physiologic changes in the woman's body during pregnancy. Which cardiovascular changes up through the 26th week should the student point out?
Increased pulse rate and decreased blood pressure *Pulse rate frequently increases during pregnancy, although the amount varies from a slight increase to 10 to 15 beats per minute. Blood pressure generally decreases slightly during pregnancy, reaching its lowest point during the second trimester.
A client calls to cancel an appointment for the first prenatal visit after reporting a home pregnancy test is negative. Which instruction should the nurse prioritize?
Keep the appointment *Although home pregnancy tests are accurate 95% of the time, they may still have false positives or false negatives, and the client needs to seek prenatal care and confirmation from her health care provider. Diluting the urine, waiting to miss a second period, or eating before the test would have no effect. The tests look for hCG, which is not affected.
The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?
Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples *All women have Montgomery glands (Montgomery tubercles). They become more prominent during pregnancy and help to prepare the nipples for breastfeeding. The bumps are not specific to pregnancy and are not a sign of cancer. They are not the result of stretching.
The nurse is assessing a client at 14 weeks' gestation at a routine prenatal visit and notes the fundal height is at the umbilicus. The nurse will most likely interpret this finding to indicate which situation?
Multiple fetal pregnancy *The fundus typically is at the level of the umbilicus at 20 weeks' gestation. Therefore the fundal height is greater than that which is expected, suggesting possible multiple gestation, polyhydramnios, fetal anomalies, or macrosomia. Smaller than expected measurements would suggest intrauterine growth retardation or possibly inadequate amount of amniotic fluid. Urinary retention would displace the uterus.
During a prenatal visit at 28 weeks' gestation, the client tells the nurse, "I am always hot now, and usually I am the one wearing an extra sweater. And I normally run a low temperature, around 98.2°F (36.7°C). But when they take it at the clinic, it is between 98.6°F and 98.9°F (37°C and 37.2°C). Do you think I have an infection?" Which responses by the nurse are appropriate in this situation? Select all that apply
Pregnant women typically are 0.4°F to 0.6°F (0.275°C) warmer than their baseline temperatures. The increased metabolic rate during pregnancy makes some women feel warmer. Do you have any signs of an infections, such as painful urination? *Pregnant women typically are 0.4°F to 0.6°F (0.275°C) warmer than their baseline temperatures. Checking for any signs of an infections, such as painful urination, would be appropriate. The increased metabolic rate during pregnancy does make some women feel warmer. This client is describing a common discomfort of pregnancy and interventions such as additional blood work or ultrasound examination are not warranted in this situation.
A nurse working in a correctional facility is monitoring a group of pregnant inmates. Which interventions might be necessary to improve the health of these incarcerated pregnant women? Select all that apply.
Provide prenatal vitamins Ensure frequent hydration Recommend activity restrictions Coordination of care with off-site providers Provide extra food and exclude unpasteurized items *
A nurse is counseling a pregnant client about maternal serum marker screening. The nurse wants to go ahead with the test to rule out anencephaly. The client understands the risks associated with the test and is worried about what to do if the test shows a positive result even if the child is completely healthy. Which nursing diagnosis would be most appropriate?
Risk for Anxiety related to false-positive test results *The most appropriate nursing diagnosis will be Risk for Anxiety related to false-positive test results. The client understands the risks associated with the test so the diagnosis should not be deficient knowledge. As the client wants to have a maternal serum marker screening test done despite her apprehensions, there is no decisional conflict. The test involves a blood specimen so the risk for infection is extremely minute.
The nurse is caring for a client who is at 37 weeks' gestation and has a biophysical profile of 10. Which nursing action is best?
Schedule a health care provider appointment for one week. *A biophysical profile of 10 is a good score indicating fetal well-being. The nurse would schedule this client for her weekly health care provider appointment. There is no need to immediately notify the health care provider, have the client report to the hospital nor prepare the records for a cesarean birth indicating the fetus needs to be born.
In assessing the dietary intake over the last 24 hours of a pregnant client, which food would be most concerning to the nurse?
Smoked salmon and bagels *Pregnant women should not eat refrigerated meats or smoked seafood unless it is part of a cooked dish. 6 ounces of white tuna, a well-cooked hot dog and a steak that is cooked thoroughly are all safe foods.
A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next?
Tell the client these are normal findings during pregnancy. *The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should document this in the chart, but it is not priority over educating the client.
The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The intestines are displaced by the growing fetus. *The growing fetus is displacing the intestines and interfering with peristalsis, delaying the passage of fecal matter and resulting in constipation. This is common and expected; however, the client should take measures to prevent hemorrhoids that can occur as the result of the pressure and straining. Progesterone, not hCG, can delay gastric emptying and decrease peristalsis.
What should the nurse explain to the pregnant client about the importance of the fetal stage of development?
There is additional growth and development of the organs and body systems. *The fetal stage is from the beginning of the ninth week after fertilization and continues until birth. At this time, the developing human is called a fetus. During the fetal stage, there is additional growth and maturation of the organs and body systems.
Which of the following changes, with highest priority, should the nurse teach a pregnant client to report to the health care provider as soon as possible?
abdominal pain coming and going during the third trimester *Any abdominal pain needs to be reported to the health care provider ASAP. This could be a sign of preterm labor and needs to be addressed. Vomiting during the first trimester is normal. Heartburn is caused by the shifting of abdominal organs. Frequent urination is the result of increased pressure on the bladder.
A woman is at 20 weeks' gestation. The nurse would expect to find the fundus at which area?
at the level of the umbilicus *The uterus, which starts as a pear-shaped organ, becomes ovoid as length increases over width. By 20 weeks' gestation, the fundus, or top of the uterus, is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy.
A pregnant woman who is a vegetarian asks the nurse, "What would you suggest to make sure that I get enough protein in my diet while I am pregnant?" Which food(s) would be appropriate for the nurse to suggest? Select all that apply.
beans lentils nuts *Ways to ensure adequate protein intake include using soy foods, beans, lentils, nuts, grains, and seeds. Orange juice and green leafy vegetables can help promote calcium and vitamin C intake.
Vitamin C deficiency can lead to what adverse effects for the gestating mother?
blood disorders such as easy bruising *A gestating mother needs vitamin C for formation of fetal bones and fetal growth. It also helps with iron absorption. A deficiency of vitamin C can cause easy bruising in the mother and, if severe, cause dental abnormalities.
A group of nursing students are preparing a presentation for a health fair illustrating the structures found during a pregnancy. Which structures should the students point out form a protective barrier around the developing fetus?
chorion and amnion *The chorion and amnion are the two fetal membranes. The ectoderm, mesoderm, and endoderm are layers in the developing blastocyst.
On day 3 after a cesarean birth, the client is complaining of soreness in her left leg. On examination the nurse notes the left leg is swollen, and the calf is red, tender and warm to touch. These findings indicate:
deep vein thrombosis. *Deep vein thrombosis is characterized by unilateral leg pain or swelling, redness, or tenderness. These assessment findings are not consistent with the presence of varicose veins, peripheral artery disease, or venous insufficiency. Varicose veins are enlarged, swollen, twisted veins often caused by damaged or faulty valves that allow blood to travel in the wrong direction. Peripheral artery disease is a common circulatory problem in which narrowed arteries reduce blood flow to your limbs, resulting in cold pale extremities. Venous insufficiency occurs when blood doesn't flow back properly to the heart, causing blood to pool in leg veins. Venous insufficiency can be a result of a DVT or varicose veins.
Which of the following findings is most worrisome in Melissa, a woman in her 26th week of pregnancy?
facial edema *Generalized hair loss, hyperpigmented maxillary rash (chloasma), and nosebleeds are usually benign and common in pregnancy. Facial edema after the 24th week of gestation may indicate gestational hypertension.
A client is at 20 weeks' gestation and is scheduled for a fetal survey with ultrasound. To confirm normal development thus far in pregnancy, which result(s) are expected? Select all that apply.
fetal femur measurement of 30 mm fetal heart beat present fetal implantation in the uterine fundus *Many providers perform a fetal survey by ultrasound at 20 weeks' gestation. The fetus is now large enough at this point for all major organs to be visible on ultrasound. Measurements of bones can be compared to expected size (29 to 31 mm at 20 weeks). Basic characteristics of the organs can identify anomalies. The fetal heart should be beating and valve functioning is identified. Down syndrome characteristics are not fully visible and an amniocentesis best confirms the chromosomal structure. The procedure also can indicate placental placement in the fundus. At this point of gestation, typically the fetal head is not show engagement in the pelvis. This occurs closer to the end of the pregnancy.
When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?
fundal height measurement *On every follow-up visit, fundal height measurements are performed to evaluate fetal growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be done on the initial visit and then repeated if the woman's status indicates a need for doing so. Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal period, but it is not done at every visit.
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
human chorionic gonadotropin (hCG) *The placenta produces hCG, which is the basis for pregnancy tests. This hormone preserves the corpus luteum and its progesterone production so that the endometrial lining is maintained. Human placental lactogen modulates fetal and maternal metabolism and participates in the development of the breasts for lactation. Estrogen causes enlargement of the woman's breasts, uterus, and external genitalia and stimulates myometrial contractility. Progesterone maintains the endometrium.
Many changes occur in the body of a pregnant woman. Some of these are changes in the integumentary system. What is one change in the integumentary system called?
melasma (chloasma) *The so-called mask of pregnancy, melasma (also known as chloasma) can appear as brown blotchy areas on the forehead, cheeks, and nose of the pregnant woman. This condition may be permanent, or it may regress between pregnancies.
A woman has just given birth to a healthy term newborn. Upon assessing the umbilical cord, the nurse would identify what findings as normal? Select all that apply.
one vein two arteries *The normal umbilical cord contains one large vein and two small arteries.
Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of:
placental insufficiency. *A deficiency of amniotic fluid, oligohydramnios, is associated with uteroplacental insufficiency and fetal renal abnormalities. Excess amniotic fluid is associated with maternal diabetes, neural tube defects, and malformations of the gastrointestinal tract and central nervous system.
A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation (dilatation) and enlargement of the birth canal. What is this hormone?
relaxin *Relaxin, secreted by the corpus luteum of the ovary as well as the placenta, is responsible for helping to inhibit uterine activity and to soften the cervix and the collagen in joints. Softening of the cervix allows for dilation (dilatation) at birth; softening of collagen allows for laxness in the lower spine and so helps enlarge the birth canal. The effect of estrogen is to cause breast and uterine enlargement. Progesterone has a major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breasts for lactation. Human placental lactogen (hPL), also known as human chorionic somatomammotropin, serves as an antagonist to insulin, making insulin less effective and thereby allowing more glucose to become available for fetal growth.
The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting?
separation of the muscles of the abdominal wall *By 20 weeks' gestation, muscles of the abdominal wall may begin to separate (diastasis recti) and not return to normal approximation until several weeks after childbirth. The term diastasis recti does not refer to the raising of the uterus into the abdomen, relaxation of the kidneys, or movement of the bladder.
A pregnant client is visiting the clinic and complains about the tiny, blanched, slightly raised end arterioles on her face, neck, arms, and chest. The nurse should explain that these are normal during pregnancy and are referred to as:
telangiectasias. *The dilated arterioles that occur during pregnancy are due to the elevated level of circulating estrogen and are called telangiectasias. An epulis is a red raised nodule on the gums that may develop at the end of the first trimester and continue to grow as the pregnancy progresses. The linea nigra is a pigmented line extending from the symphysis pubis to the top of the fundus during pregnancy. Striae gravidarum (stretch marks) are slightly depressed streaks that commonly occur over the abdomen, breast, and thighs during the second half of pregnancy.
A client is to have an amniocentesis with ultrasound. What does the nurse explain to the client that amniocentesis can determine? Select all that apply.
the amniotic fluid can be used for genetic testing whether the fetal lungs are mature enough to support respiration outside of the womb *Amniotic fluid provides a great deal of information. During pregnancy, a procedure called an amniocentesis can obtain a sample of amniotic fluid. The practitioner can analyze the fluid to determine whether the fetal lungs are mature enough to support respiration outside of the womb. The fluid can also be used for genetic testing because the fluid contains fetal cells with fetal DNA
A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client?
with a pillow under her right hip *Pregnancy places strain on the cardiovascular system with increased fluid in the lungs and heart. The use of one pillow under the right hip will help displace the uterus and fetus off the major blood vessels, allowing the circulation to flow appropriately and provide relief to the client. When the woman lies flat on her back the uterus and contents can compress the vena cava and aorta and reduce blood flow, resulting in the light-headedness and dizzy spells. Removal of the pillow would not alter the effects on the vena cava. A pillow under the shoulders would hurt the neck, and a pillow under both hips would exacerbate the light-headedness.
