RICCI Chapter 12
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 nurse advises a pregnant client to keep a small high-carbohydrate, low-fat snack at the bedside. The nurse should point out this will assist with which condition?
Nausea and vomiting
A woman who professes to be a strict vegetarian voices concerns about her ability to meet the nutritional needs of her fetus. Which concerns should be addressed in this session?
The supplementation of Vitamin B12 should be addressed. Vitamin B12 is almost exclusively met via animal sources.
During her first prenatal visit, a woman 18 weeks pregnant reports she did not realize she was pregnant and continued to take her birth control pills. She is concerned about their effects on her baby. Which of the following would be the best response to her concerns?
"Because of concerns about the estrogen exposure to the baby, we will monitor the fetal development." Studies have demonstrated a correlation between fetal growth problems and increased estrogen exposure.
The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which patient statement indicates that the nurse's efforts have been successful?
"It was so nice to not have to wait long in the waiting room." Strategies to individualize prenatal care include trying to schedule appointments so there won't be a long wait time, providing privacy for weight and blood pressure assessments, educating on care options and encouraging participating in decisions about care, and providing materials on pregnancy in the waiting room.
The nurse is reviewing client data following a regular monthly appointment at 6 months' gestation. Which fundal height requires no further intervention?
24 cm An anticipated fundal height for 24 weeks' gestation (6 months) is 24 cm. Between 18 and 32 weeks gestation, the fundal height in centimeters should match the gestational age. All of the other measurements would require further intervention.
A client comes to the clinic for her usual prenatal check up. The nurse measures the fundal height at 24 cm. What is the estimated length of her gestation?
24 weeks Fundal height is an approximation of the number of weeks of gestation. Between 20 to 32 weeks, SFH = gestation in weeks + or - 2 cm.
A pregnant patient is experiencing a vaginal discharge and wants to douche. What should the nurse instruct the patient about this health practice?
Avoid routine douching. Douching while pregnant is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix and lead to uterine infection. In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth. The alkalinity, purchase type, or temperature of the solution does not matter. The pregnant patient should not douche.
During the physical exam at the first prenatal visit a speculum exam is performed. What sign of pregnancy does the practitioner look for during the speculum exam?
Chadwick's sign
A pregnant woman tells you that she wants to avoid saturated fat by using vegetable oil. What is another advantage of vegetable oil?
Contains linoleic acid Linoleic acid is a fat important for skin integrity in the mother and for fetal growth.
A woman in early pregnancy is concerned because she is nauseated every morning. Which measure would be best to help relieve this?
Delay breakfast until midmorning
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.
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of a miscarriage within the first trimester. The nurse is correct to document the history as:
G = 3, T = 1, P = 0, A = 1, L = 1 The GTPAL stands for Gravida -- number of pregnancies, which is 3 (current, 4 year old and miscarriage); Term -- only one pregnancy thus far carried to term; Preterm deliveries -- 0; Abortions (including miscarriages) -- 1; Living children -- 1. All other options are incorrect. Do not be distracted by the twins. That is still one pregnancy.
A client presents to the office for her obstetric history. She tells the nurse she has 4 children living at home. One child was born at 34 weeks, another child at 37 weeks, two were born consecutively at 38 and 39 weeks, and one was aborted. Record the client's obstetric record using the GTPAL format.
G5, T2, P2, A1, L4 "G" stands for gravida, the total number of pregnancies (5). "T" stands for term, the number of pregnancies that ended at term (at or beyond 38 weeks' gestation)(2). "P" is for preterm, the number of pregnancies that ended after 20 weeks' gestation (2). "A" is for abortions, either spontaneous or induced (1). "L" is for living, the number of children delivered who are alive at the time of history collection (4).
How should the nurse record the obstetric history for a newly pregnant client who previously delivered two live infants at term and had one abortion at 12 weeks' gestation?
Gravida 4, para 2 Gravida is defined as a woman who has been pregnant or is currently pregnant, regardless of gestation. Para is defined as the number of pregnancies that have reached viability, regardless of whether the infants were born alive or the number of infants delivered from that pregnancy. The client was pregnant three times in the past and is currently pregnant (Gravida 4). The client delivered two live births (Para 2). The aborted fetus is not included in the para count.
A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her?
Health-seeking behaviors related to ways to relieve discomforts of pregnancy Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.
A nurse is providing care to a pregnant woman. To promote optimal outcomes, the nurse would engage in which activity? Select all that apply.
Individualized assessment Counseling Teaching
A pregnant patient is planning travel to a foreign country as part of a work assignment and needs immunizations. What should the nurse instruct the patient about immunizations while pregnant?
Live virus immunizations are contraindicated while pregnant. All live virus vaccines are contraindicated during pregnancy and should not be administered unless the risk of the disease outweighs the risk to the pregnancy because live virus vaccines can cross the placenta and infect the fetus. The influenza vaccine is recommended if it is flu season when visiting crowded locations.
During a previous prenatal visit, the nurse focused on the importance of adequate nutritional intake with a pregnant patient. Which assessment findings indicate that this teaching has been effective? (Select all that apply.)
Normal muscle reflexes Shiny hair Smooth tongue
A nurse is caring for a client who is 8 months pregnant. Which instruction is the nurse most likely to give her?
Rest on the left side for at least 1 hour in the morning and afternoon.
An adolescent asks which sport would be safe for her to learn during pregnancy. Which activity should the nurse suggest to the patient?
Swimming Swimming is a good activity for pregnant women and is not contraindicated as long as membranes are intact. It increases muscle tone but may help relieve backache. Pregnancy is not the time to learn to ski or ride a bicycle because the lack of skill could result in many falls. Jogging is questionable because of the strain the extra weight of pregnancy places on the knees.
A potential complication for the mother and fetus is Rh incompatibility; therefore, assessment should include blood typing. If the mother is Rh negative, her antibody titer should be evaluated. If treatment with Rho(D) immune globulin is indicated, the nurse would expect to administer it at which time?
at 28 weeks
Gestational diabetes occurs around the 24th week of gestation. When should every woman be screened for gestational diabetes?
between 24 and 28 weeks' gestation
While assessing a client's breast during the third trimester, which finding would the nurse expect?
colostrum from the nipples During the third trimester, the nipples express colostrum. Areolae and nipples appear enlarged with darker pigmentation during the third trimester. The nurse assesses for the softness of the breast, color, and pain in the nipple area in nursing mothers.
When preparing a class for a group of pregnant women about nicotine use during pregnancy, the nurse describes the major risks associated with nicotine use including:
decreased birth weight in neonates. The nurse should inform the client that children born of mothers who use nicotine will have a decreased birth weight. Spontaneous abortion is associated with caffeine use. Increased risks of stillbirth and placenta abruptio are associated with mothers addicted to cocaine.
A pregnant woman experiences frequent leg cramps. Which measure would the nurse include in her teaching plan to provide her with relief?
extending her knee and dorsiflexing her foot Dorsiflexing the foot with the knee extended is an effective method for relieving cramps in the calf muscle, the most frequently affected muscle.
A pregnant client tells the nurse that she has a 2-year-old child at home who was born at 38 weeks; she had a miscarriage at 9 weeks; and she gave birth to a set of twins at 34 weeks. Which documentation would be appropriate for the nurse?
gravida 4, para 2 Gravida (G) indicates the number of pregnancies. When a nurse calculates the GTPA of a pregnant client, the current pregnancy counts and the three other pregnancies count for a total of four pregnancies. Para (P) indicates the number of pregnancies carried to viable gestational age. This client has had two viable pregnancies so far.
The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider. Which signs and symptoms would the nurse include? Select all that apply.
headache with visual changes in the third trimester sudden leakage of fluid during the second trimester lower abdominal pain with shoulder pain in the first trimester
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy?
soft systolic murmur
The nurse is assisting a primigravid on calculating the due date of her baby using Naegele rule. The most important information provided by the mother is:
the first day of the last menstrual period. Naegele rule is calculated using the first day of the last menstrual period. From there, 7 days are added and then 3 months are subtracted. The ovulation date, intercourse date nor last day of the menstrual period is needed.
A nurse is teaching a client who is 30 weeks pregnant about ways to deal with heartburn. The nurse determines a need for additional teaching based on which client statement?
"I should lie down for 1/2 hour after eating." The client should remain sitting for 1 to 3 hours after eating and avoid lying down within 3 hours of eating. Cutting out caffeine, chewing food slowly, and raising the head of the bed are helpful in reducing heartburn of pregnancy.
A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?
Elevate the head of the bed. Heartburn is a common problem worsening as the pregnancy progresses. The pregnancy hormones relax the lower esophageal sphincter, resulting in increased heartburn. Elevation of the head of the bed will help prevent the acid from refluxing. Exercise does not negatively impact heartburn and should be continued. The pregnant mother should not take any medication that is not prescribed by her primary care provider. Heartburn is not a medical emergency.
A woman reports to the clinic to have her IUD checked. During the visit it is determined she is 6 weeks pregnant. How will the presence of the IUD be handled?
It will be removed to allow the pregnancy to grow. The IUD must be removed to allow room for safe growth and development for the embryo.
During a prenatal examination, the nurse learns that a pregnant patient has a supernumerary nipple. What should the nurse teach the patient about this finding?
Such growths deepen in color during pregnancy.
When discussing rest and sleep with a pregnant woman, the nurse would discuss which position to use for napping?
on her side with the weight of the uterus on the bed Resting on the side prevents pressure from the uterus against the vena cava and, therefore, allows blood to return to the uterus.
A pregnant patient is concerned that orgasm will be harmful to the developing fetus. What should the nurse include when responding to this patient's concern?
Some women experience orgasm intensely during pregnancy. Because of increased pelvic congestion from the additional uterine blood supply at midpregnancy, most women notice increased clitoral sensation and may experience orgasm for the first time during pregnancy because of this. Orgasm during pregnancy is not harmful. Pelvic congestion does not make orgasm painful
A pregnant patient enjoys exercising at a local health spa once a week. Which patient comment indicates to the nurse that additional health teaching is needed?
"Nothing feels nicer than a hot tub soak after exercise." Pregnant women should not soak for long periods in extremely hot water or hot tubs because heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. Playing table tennis, performing low-impact aerobics, and the environment of the gym are not comments that indicate the need for additional teaching.
The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed?
"Pain with urination is expected during pregnancy." Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional patient teaching is needed. The patient should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy.
The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age?
20 weeks
Which information is most important in order to decrease the risk of complications if the client decides to work until her due date?
Frequent rest periods It is common to have a client work until she goes into labor providing she has had a low risk pregnancy. Frequent rest periods are stressed, if possible, as the client progresses throughout the work day. The other options are good suggestions for any client at the end of pregnancy.
A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching?
"I should substitute intercourse with nonsexual touch to avoid harming the fetus."
The nurse is providing education regarding fetal kicks/movement to a 22 weeks primigravid in the family planning clinic. Which client statement indicates an understanding of the teaching?
"I will document fetal kicks/movement daily and they should be 10 every 2 hours."
A nurse is 5 weeks pregnant and works on a care area where chemotherapy is administered to patients. Which statement indicates that this nurse needs additional health teaching about avoiding teratogens during pregnancy?
"Latex gloves irritate my hands, so I don't use them."
During the interview portion of her first prenatal visit, a woman reports she thinks she may have a vaginal infection. When questioned, she reports the discharge is thick, greenish-yellow, and she is very uncomfortable. She reports she thinks it is "yeast." How should the nurse reply?
"Yeast is usually a thick, cheesy, white discharge so we will need to evaluate it during the pelvic exam." Yeast is normally a thick, cheesy discharge. Greenish-yellow discharge is associated with gonorrhea.
How should the nurse document a pregnant patient's gestational status using the GTPAL system after collecting the following data? Currently 18 weeks pregnant Patient's fourth pregnancy Delivered one nonviable fetus at 26 weeks Experienced one miscarriage Delivered one viable fetus at 38 weeks' gestation
4, 1, 1, 1, 1 GTPAL is a more comprehensive system for classifying pregnancy status. By this system, the gravida classification remains the same, but para is broken down into T: the number of full-term infants born (infants born at 37 weeks or after), P: the number of preterm infants born (infants born before 37 weeks), A: the number of spontaneous miscarriages or therapeutic abortions, and L: the number of living children. The patient has been pregnant four times. The patient delivered one viable infant at 38 weeks. The patient delivered one nonviable fetus at 26 weeks. The patient had one miscarriage. The patient has one living child.
You encourage a pregnant woman to eat a diet high in complete protein. Assuming she likes all of the following foods, which of them would you recommend as a source of this for her?
A boiled or fried egg Complete protein is supplied by animal or fowl sources.
The nurse is planning nutritional instructions for a pregnant patient who is a Mexican immigrant. On which areas should the nurse focus when preparing teaching for this patient? (Select all that apply.)
Add fruits rich in vitamin C. Increase the intake of dairy products Reduce the cooking time of vegetables Limit the amount of added animal fat in foods. In the Mexican culture, most vegetables are cooked for a long time so they lose most of their nutritional value. Diet is high in fiber and starch. Animal fat is frequently added during food preparation. The diet may be inadequate in calcium, iron, vitamin A, and vitamin C. The nurse should instruct the patient to add fruits rich in vitamin C, increase dairy product intake, reduce cooking times of vegetables, and limit the amount of animal fat in the diet.
A client in the third trimester of pregnancy has to travel a long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client?
Always wear a three-point seat belt. To promote easy and safe travel for the client, the nurse should instruct the client to always wear a three-point seat belt to prevent ejection or serious injury from collision. The nurse should instruct the client to deactivate the air bag if possible. The nurse should instruct the client to apply a nonpadded shoulder strap properly, ensuring that it crosses between the breasts and over the upper abdomen, above the uterus. The nurse should instruct the client to use a lap belt that crosses over the pelvis below—not over—the uterus.
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure?
Amniocentesis Amniocentesis is an invasive procedure whereby a needle is inserted into amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with Rh(D)-negative blood, since the puncture can allow the seepage of blood and amniotic fluid into the woman's system. She should receive RhoGAM after the procedure to protect her and future babies. The CST, NST, and a biophysical profile are noninvasive tests.
A woman in early pregnancy asks you why she has palmar erythema. Your reply would be based on the principle that palmar erythema is most likely caused by which of the following?
An increased estrogen level
What advice should the nurse provide to a patient who is 4 months pregnant and owns a cat?
Ask someone else to change the cat litter. Toxoplasmosis, a protozoan infection, may be contracted through handling cat stool in soil or cat litter. Removing a cat from the home during pregnancy as a means of prevention is not necessary as long as the cat is healthy. The pregnant woman should be instructed not to change a cat litter box or garden in soil in an area where cats may defecate to avoid exposure to the disease. Cleaning the cat's dish is acceptable. Scratches do not cause the disease.
Why is the first prenatal visit usually the longest prenatal visit?
Baseline data is collected. The first prenatal visit is usually the longest because the baseline data to which all subsequent assessments are compared are obtained at this visit.
The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize?
Be certain she is aware of potential complications. The client should be aware of the potential complications and risks, and should sign an informed consent. Narcotics are contraindicated for pregnant woman due to side effects. She should maintain bed rest for the remainder of the day, with light housework the following day and a return to normal activities on the third day. It may take 2 or 3 weeks before the test results come back from the laboratory.
A woman relates to the nurse that she understands that dietary fat is bad for her and that she should avoid it during pregnancy. How should the nurse respond?
Fats are essential during pregnancy, and vegetable oils are a good source
A woman who is 4 months pregnant has pyrosis. Which suggestion would the nurse give her?
Eat small meals and do not lie down after meals. Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the stomach causes regurgitation into the esophagus. Eating small meals and remaining upright limits the possibility of regurgitation.
The nurse is teaching a pregnant client some nonpharmacologic ways to handle common situations encountered during pregnancy. The nurse determines the session is successful when the client correctly chooses which condition that can be minimized if she avoids drinking fluids with her meals?
Heartburn Filling the stomach with heavy food and fluid can cause overfill and place pressure on the stomach, increasing gastric reflux. Avoid excess fluids with meals and eat small frequent meals to avoid heartburn. Nosebleeds result from increased estrogen. Blood clots can result from sitting still for too long. Constipation can result from increased progesterone.
The nurse is caring for a neonate whose mother received no medical care for either of her pregnancies. When assessing the neonate's status, which would indicate a potential A, B, and O incompatibility?
Hemolytic anemia Antibody screens are done to recognize women who may be at risk of developing antigen incompatibilities with fetal red blood cells. If the incompatibility develops, and is not addressed quickly, the neonate may develop hemolytic anemia as the mother's antibodies cross the placenta and attack the fetus's red blood cells. Hypothyroidism can affect the fetus's nervous system. Dehydration may lead to electrolyte deficiencies. Abnormal bleeding is less common due to the initiation of Vitamin K.
A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?
Stop and walk every 2 hours. Walking increases venous return and reduces the possibility of thrombophlebitis, a risk for pregnant women who sit for extended periods of time. Limiting mileage, sitting in the back with the feet elevated, and limiting trips may help, but they are not enough to prevent phlebitis.
Why is a Papanicolaou smear done at the first prenatal visit?
It identifies abnormal cervical cells. A Pap smear is a test for cervical cancer. Should abnormal cells be present, the woman may need to make a decision about her priorities of therapy for cervical disease or continuing the pregnancy.
The nurse is determining the effectiveness of nutritional teaching with a pregnant patient. Which food item that the patient selects indicates that additional teaching on good sources of iron is needed?
Milk The foods richest in iron include organ meats; eggs; green, leafy vegetables; whole grains; enriched breads; or dried fruits. Milk is not a good source of iron and indicates that additional teaching is needed.
The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage?
Stretching and breathing exercises such as yoga It is important to exercise during pregnancy. One excellent type of exercise includes yoga, which reduces stress and increases relaxation. Yoga also gently stretches muscles and can increase muscle tone. Contact and high impact sports are not appropriate for the pregnant mother. Hot areas such as in a jacuzzi, hot tub and sauna are also inappropriate.
The nurse is planning a class for nurses learning to teach early prenatal classes. Which statement indicates that teaching has been effective?
The goal of early prenatal care is to optimize the health of the woman and the fetus. Early prenatal classes or first trimester classes include early gestational changes, self care, fetal development and environmental dangers for the fetus, sexuality, birth settings and types of providers, nutrition, rest, exercise, relief measures for discomforts, coping with stress, psychological changes for both woman and her partner, getting the pregnancy off to a good start, availability of prenatal and genetic screening, risk factors for preterm labor and other pregnancy-related conditions, and how to recognize symptoms and what to do if they occur. Although all the answers are essentially correct, optimizing the health of the woman and fetus is the best answer.
A pregnant woman states that she would like to take a tub bath but has heard from her aunt that this could be dangerous to the baby. Which instruction should the nurse give to the client?
Tub baths are fine unless you are unstable on your feet or are experiencing vaginal bleeding.: Daily tub baths or showers are recommended. Women should not soak for long periods in extremely hot water or hot tubs, however, as heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. As pregnancy advances, a woman may have difficulty maintaining her balance when getting in and out of a bathtub. If so, she should change to showering or sponge bathing for her own safety. If membranes rupture or vaginal bleeding is present, tub baths become contraindicated because there might be a danger of contamination of uterine contents. Soap is not a teratogen to the fetus.
A client in her third trimester reports to the nurse shortness of breath when sleeping. The nurse informs the client that this is normal and occurs because the growing fetus puts pressure on the diaphragm. Which measure should the nurse suggest to help alleviate this problem?
Use extra pillows. The nurse should instruct the client to use extra pillows at night to keep her more upright. The nurse can instruct the client to use a firmer mattress if the client is experiencing backache. The nurse can ask the client to avoid overeating and ingesting spicy food in case the client is experiencing heartburn.
A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location?
at the umbilicus
A nurse is taking a history during a client's first prenatal visit. Which assessment finding would alert the nurse to the need for further assessment?
history of diabetes for 4 years A diagnosis of diabetes in a pregnant client increases risk for both the client and the infant during pregnancy and requires close monitoring and follow up. This client's age, exercise history, and history of occasional OTC pain reliever use do not increase pregnancy risk.