Saunders | Prenatal Period

265. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery

1. A normal test result - A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period.

275. The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? 1. Increase in pulse rate 2. Increase in blood pressure 3. Frequent bowel elimination 4. Decrease in red blood cell production

1. Increase in pulse rate - Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/minute, which then persists to term. - The blood pressure usually is the same as the prepregnancy level, but then gradually decreases up to about 20 weeks of gestation. - During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg. - During pregnancy, there is an accelerated production of red blood cells.

270. A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps? 1. "Bend your foot toward your body while flexing the knee when the cramps occur." 2. "Bend your foot toward your body while extending the knee when the cramps occur." 3. "Point your foot away from your body while flexing the knee when the cramps occur." 4. "Point your foot away from your body while extending the knee when the cramps occur."

2. "Bend your foot toward your body while extending the knee when the cramps occur."

272. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

2. "I need to lie flat on my back to perform the procedure." - Sit or lie quietly on her side to perform kick counts. - Need to notify HCP if she feels fewer than 10 kicks *over two, 2-hour intervals* or as instructed by her HCP.

271. A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. - Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. - The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. - The live attenuated rubella virus is not communicable in breast milk. - Counsel not to become pregnant for 1 to 3 months after immunization because of a possible risk to a fetus from the live virus vaccine - Avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids.

276. The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. "I should avoid between-meal snacks." 2. "I should lie down for an hour after eating." 3. "I should use spices for cooking rather than using salt." 4. "I should avoid eating foods that produce gas and fatty foods."

4. "I should avoid eating foods that produce gas and fatty foods." - Avoid BOTH spices, along with salt, because spices trigger heartburn. Salt produces edema.

269. The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. "I should wear panty hose." 2. "I should wear support hose." 3. "I should wear flat nonslip shoes that have good support." 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."

4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours." - Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. - Encourage to wear support hose or panty hose.