Test 1 Review Ch 15-16
When do Goodell and Hegar's signs occur?
Between 6-8 weeks
What are the changes a woman's uterus undergoes during pregnancy?
- Weight increases from 70g to 1100-1200g at term - Capacity increases from 10 to 5,000 mL or more - Uterine walls thin to 1.5 cm or less; from a solid glove the uterus becomes a hollow vessel
When is testing for AFP conducted?
An elevated AFP level in a pregnant client could indicate the presence of some type of spinal cord defect. Testing is usually performed around 16 to 18 weeks' gestation and requires follow-up.
When discussing the many changes the woman's body undergoes during pregnancy, the nurse may include that the woman's total blood volume will increase by approximately how much by the 30th week gestation? 1,500 mL 1,000 mL 500 mL 2,000 mL
Blood volume increases by approximately 1,500 mL or 50% above nonpregnant levels by the 30th week gestation. This increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues.
A nurse is teaching a group of primigravida woman who are in their first trimester. One of the women asks the nurse about sexual activity during pregnancy. Which information would the nurse most likely incorporate into the response? Female orgasm on the EDC will cause labor to begin. Intercourse is not recommended before 36 weeks because it can induce labor. Women who have a partially dilated or effaced cervix at term must refrain from sexual activity. Because of pelvic congestion, women may experience increased clitoral sensitivity.
Correct response: Because of pelvic congestion, women may experience increased clitoral sensitivity. Explanation: Only a few complications of pregnancy such as vaginal bleeding and ruptured membranes limit sexual activity. A partially dilated cervix does not warrant a restriction in sexual activity.
A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucous discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse? "It might be nothing. If it happens again call your provider who is on-call." "If the provider did an exam, it might be just normal vaginal secretions, so don't worry about it." "A one time discharge of bloody mucus in the toilet might have been your mucous plug." "Bloody mucus is a sign you are in labor. Please come to the hospital."
Correct response: "A one time discharge of bloody mucus in the toilet might have been your mucous plug." Explanation: Bloody mucus can either be a mucous plug or bloody show. The one time occurrence would be more likely to be the mucous plug. A bloody show would continue if her cervix was changing, but this usually does not occur until after contractions start. It is a sign that something is happening and should be reported to the health care provider. The bloody mucus is not a sign of labor, but it can be an early sign that labor is coming soon.
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge teaching to address this issue? "You may have intercourse until next month with no fear of pregnancy." "Ovulation may return as soon as 3 weeks after birth." "You will not ovulate until your menstrual cycle returns." "Ovulation does not return for 6 months after birth."
Correct response: "Ovulation may return as soon as 3 weeks after birth." Explanation: Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.
A client in her second trimester of pregnancy arrives at the health care facility for a routine follow-up visit. The nurse is required to educate the client so that the client knows what to expect during her second trimester. Which information should the nurse offer? "You may feel physical discomfort as the baby inside grows." "You will experience quickening, and you will actually feel the baby." "You will be more conscious of the changes taking place in your body now." "You may have mood swings that could overwhelm your partner."
Correct response: "You will experience quickening, and you will actually feel the baby." Explanation: The nurse should inform the client that quickening occurs in the second trimester. The client will be able to physically feel the fetal movements, which will help her bond with her developing fetus. Physical discomfort actually starts to increase in the third trimester as the fetus grows rapidly. The client feels conscious of the changes taking place in her body due to her pregnancy primarily in the first trimester, not the second. The client is likely to have mood swings in the first trimester of the pregnancy, which can be very overwhelming for the client as well as her partner.
A pregnant client presents for her first prenatal visit. She informs the nurse that she had an ectopic pregnancy 3 years ago. She ask the nurse if this would happen this time. Which response by the nurse would be best? "You should not worry about this right now—stress can harm the fetus." "Be calm. Why worry about things that likely won't happen?" "Your statistical risk of another tubal pregnancy is increased." "Just because you had one ectopic pregnancy does not mean you will have another."
Correct response: "Your statistical risk of another tubal pregnancy is increased." Explanation: If a woman has had tubal/ectopic pregnancy, her statistical risk of another tubal pregnancy is increased. The other comments are not therapeutic and do not supply accurate information or address the client's legitimate concerns.
A client in her first trimester is concerned about how weight gain will affect her appearance and questions the nurse concerning dietary restrictions. How much weight gain should the nurse point out will be safe for this cleint with a low BMI? 25 to 35 pounds (11 to 16 kilograms) 28 to 40 pounds (13 to 18 kilograms) 15 to 25 pounds (7 to 11 kilograms) 16 to 30 pounds (7.25 to 14 kilograms)
Correct response: 28 to 40 pounds (13 to 18 kilograms) Explanation: The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms). The women who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18 kilograms). Less than 28 pounds (13 kilograms) may hinder fetal development, and weight gain over 40 pounds (18 kilograms) may be dangerous to the mother. Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms). A weight gain of less than 16 pounds (7.25 kilograms) may result in a low-birth weight infant and gains over 30 pounds (14 kilograms) may necessitate a cesarean section.
At the first prenatal visit of all clients who come to the clinic appropriate blood screenings are obtained. The nurse realizes that a hemoglobin A1c above which level is concerning for diabetes and warrants further testing? 6.5% 6.0% 5.5% 5.0%
Correct response: 6.5% Explanation: A hemoglobin A1c level of at least 6.5% is concerning for overt diabetes and further testing should be conducted to ensure the client is not diabetic. If glucose testing is not diagnostic of overt diabetes, the woman should be tested for gestational diabetes from 24 to 28 weeks of gestation with a 75-gm oral glucose tolerance test.
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks pregnant. The nurse would expect this woman's heart rate to be approximately: 85 beats per minute. 90 beats per minute. 95 beats per minute. 100 beats per minute.
Correct response: 85 beats per minute. Explanation: During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per minute.
A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time? 3:30 a.m. 5:15 a.m. 7:45 a.m 9:00 a.m.
Correct response: 9:00 a.m. Explanation: If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.
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? The heart rate increase may indicate that the client is experiencing cardiac overload. The blood pressure should be higher since the cardiac volume is increased. Both findings are normal at this point of the pregnancy. Combined, both of these findings are very concerning and warrant further investigation.
Correct response: Both findings are normal at this point of the pregnancy. Explanation: 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 pregnant woman is concerned about the recent onset of a midline swelling that is soft and nontender. The nurse should point out this is most likely related to which condition? Linea nigra Chadwick sign Round ligament pain Diastasis recti
Correct response: Diastasis recti Explanation: In advanced pregnancy muscle tone diminishes, which may aid in the separation of the rectus abdominis muscles. This benign finding does not usually cause other symptoms. The nurse may palpate the fetus well through this opening. Linea nigra is a hyperpigmentation along the midline. Chadwick sign is the bluish tinge to the cervix and vaginal walls seen early in pregnancy, and round ligament pain occurs as the uterus enlarges. This discomfort is usually found in the right more often than the left.
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate? Refer her for cardiac catheterization. Ask another nurse to assess the heart. Inquire if the client has chest pain. Document this and continue to monitor the murmur at future visits.
Correct response: Document this and continue to monitor the murmur at future visits. Explanation: Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal.
A nurse is assessing a pregnant client. The nurse understands that hormonal changes occur during pregnancy. Which hormones would the nurse most likely identify as being inhibited during the pregnancy? FSH and LH FSH and T4 T4 and GH LH and MSH
Correct response: FSH and LH Explanation: During pregnancy, FSH and LH are both inhibited as there is no need to develop a follicle and release an ovum. There is an increase in the secretion of T4 and MSH. There is a decrease in the production of GH and MSH but not an inhibition.
The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: TSH slightly elevated, glucose in the urine, complete blood count low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition? Preeclampsia Anemia Hypothyroidism Gestational diabetes
Correct response: Gestational diabetes Explanation: Glycosuria, glucose in the urine, may occur normally during pregnancy, however if it appears in the urine, the patient should be sent for test to rule out gestational diabetes. Preeclampsia, anemia, and hypothyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hyperthyroidism instead of hypothyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.
The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize? Hemoglobin 13 gm/dL and hematocrit 40 percent in a woman who has given birth vaginally Hemoglobin 12 gm/dL and hematocrit 38 percent in a woman who has given birth vaginally Hemoglobin 11 gm/dL and hematocrit 34 percent in a woman who has given birth by cesarean Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean
Correct response: Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean Explanation: First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 mL of blood lost during the delivery process, the hemoglobin should decrease by 1 gm/dL and the hematocrit by 2 percent. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 mL to 500 mL and for a cesarean delivery approximately 500 mL to 1000 mL. The loss of hemoglobin from 14 gm/dL to 9 gm/dL is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 mL of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.
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? Intrauterine growth retardation Multiple fetal pregnancy Deficient amniotic fluid Urinary retention
Correct response: Multiple fetal pregnancy Explanation: 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 the early postpartum period, a new mother is displaying dependent behaviors. What behaviors would the nurse recognize as normal for this period? Select all that apply. Needing assistance with changing her peripad Desiring to hold her infant Telling the nurse about her delivery experience. Asking the nurse to take the newborn away so she can rest. Changing her newborn's diaper with guidance from the nurse.
Correct response: Needing assistance with changing her peripad Telling the nurse about her delivery experience. Asking the nurse to take the newborn away so she can rest. Explanation: In the early postpartum period, the new mother is focused upon herself and concerned about her needs. She is very dependent, having difficulty making decisions and requesting help with self-care. She relives the delivery experience and wants to it with others. This period may last several hours or several days.
A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition? Keep the client's legs slightly elevated. Place the client in an orthopneic position. Keep the head of the client's bed slightly elevated. Place the client in the left lateral position.
Correct response: Place the client in the left lateral position. Explanation: The symptoms experienced by the client indicate supine hypotension syndrome. When the pregnant woman assumes a supine position, the expanding uterus exerts pressure on the inferior vena. The nurse should place the client in the left lateral position to correct this syndrome and optimize cardiac output and uterine perfusion. Elevating the client's legs, placing the client in an orthopneic position, or keeping the head of the bed elevated will not help alleviate the client's condition.
The primigravida client is surprised by the continued uterine contractions while holding her new baby. Which explanation by the nurse will best explain these contractions? Returns the uterus to normal size Seals off the blood vessels at the site of the placenta Stops the flow of blood Closes the cervix
Correct response: Seals off the blood vessels at the site of the placenta Explanation: The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, the other options are secondary to the constriction of blood vessels at the placental site.
During a routine antepartal visit, a pregnant woman reports a white, thick, vaginal discharge. She denies any itching or irritation. Which action would the nurse do next? Notify the healthcare provider of a possible infection. Tell the woman that this is entirely normal. Advise the woman about the need to culture the discharge. Check the discharge for evidence of ruptured membranes.
Correct response: Tell the woman that this is entirely normal. Explanation: Vaginal secretions increase during pregnancy and this is considered normal leukorrhea based on the woman's report that she is not experiencing any itching or irritation. There is no evidence indicating the need to notify the healthcare provider, check for rupture of membranes, or advise her about the need for a culture.
A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? Avoid using soap for any perineal care. Wash her perineum with her daily shower. Use an alcohol wipe to wash her episiotomy line. Refrain from washing lochia from the suture line.
Correct response: Wash her perineum with her daily shower. Explanation: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
A woman in her first trimester of pregnancy has noted an increase in a thick, whitish vaginal discharge even though she showers daily. The woman shares this information with the clinic nurse who provides some client education on the topic of leukorrhea. Which interventions should be addressed in this discussion? Select all that apply. Wear cotton underwear during the day. A perineal pad to absorb the discharge may help. Tampons are the most reliable product to control the flow during the day. It is normal for the discharge to change in color or odor. Many woman find douching to provide a feeling of cleanliness.
Correct response: Wear cotton underwear during the day. A perineal pad to absorb the discharge may help. Explanation: Leukorrhea, a whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen level and the increased blood supply to the vaginal epithelium and cervix in pregnancy. Wearing cotton underpants and sleeping at night without underwear can be helpful. Some women may need to wear a perineal pad to absorb the discharge. Caution women not to use tampons because this could lead to stasis of secretions and subsequent infection. Advise women to contact their obstetric provider if there is a change in the color, odor, or character of this discharge as these suggest infection. Caution women not to douche; douching is contraindicated generally, and especially throughout pregnancy.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: acutely decreased. acutely increased. slightly decreased. slightly increased.
Correct response: acutely decreased. Explanation: Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.
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 at 32 weeks at 36 weeks only at birth
Correct response: at 28 weeks Explanation: If indicated, Rho(D) immune globulin should be given at 28 weeks for prophylaxis and again following birth if the infant is Rh+.
Which possible complication associated with back pain can lead to premature contractions? increased intracranial pressure leak of spinal fluid into the epidural space herniated disc bladder or kidney infection
Correct response: bladder or kidney infection Explanation: Obtaining a detailed account of a woman's back symptoms is crucial because back pain can be an initial sign of a bladder or kidney infection. Increased ICP, spinal fluid leak, and a herniated disc are usually not associated with back pain during a normal pregnancy.
A client with hyperemesis gravidarium is started on TPN. What parameter does the nurse need to assess at least twice a day? blood glucose hemoglobin and hematocrit blood ketones potassium level
Correct response: blood glucose Explanation: The blood glucose level needs to be tested. If it is elevated, it suggests the concentration of glucose is too high for the body to metabolize.
A client is in her second trimester, and the health care provider has recommended she undergo an amniocentesis. The nurse explains that the procedure is used to diagnose which conditions? Select all that apply. chromosomal abnormalities inborn errors of metabolism neural tube defects Rh incompatibility HIV
Correct response: chromosomal abnormalities inborn errors of metabolism neural tube defects Explanation: Amniocentesis is performed in the second trimester, usually between 15 and 18 weeks gestation. Over 40 different chromosomal abnormalities, inborn errors of metabolism, and neural tube defects can be diagnosed with amniocentesis. It can replace a genetic probability with a diagnostic certainty, allowing the woman and her partner to make an informed decision about their options. Rh incompatibility and HIV status are both evaluated by blood tests.
During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called? pseudo pregnancy pregnancy syndrome couvade syndrome cretinism
Correct response: couvade syndrome Explanation: Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partner. This phenomenon is called couvade syndrome.
Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to: detect fetal heart sounds with a Doppler. feel fetal movements. hear the fetal heartbeat with a stethoscope. palpate the fetal outline.
Correct response: detect fetal heart sounds with a Doppler. Explanation: Fetal heart sounds are audible with a Doppler at 10 to 12 weeks of gestation but cannot be heard through a stethoscope until 18 to 20 weeks of gestation. Fetal movements can be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around 20 weeks' gestation. The fetal outline is also palpable around 20 weeks of gestation.
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? increased white blood cell count stirrup injury during birth increased coagulation factors decreased red blood cell count
Correct response: increased coagulation factors Explanation: The woman is showing signs of thromboembolism or deep vein thrombosis which is a risk for the postpartum client due to the increased hypercoagulable state which occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors which the body uses as a protective device, however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, then the client should be evaluated for anemia. The stirrups should not cause an injury.
Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother? indirect Coombs' test CBC with differential ANA titer screen
Correct response: indirect Coombs' test Explanation: The indirect Coombs' test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to evaluate for immunization and autoimmune disorders.
A nurse who has been caring for a pregnant client understands that the client has pica and has been regularly consuming soil. For which condition should the nurse monitor the client? iron-deficiency anemia constipation tooth fracture inefficient protein metabolism
Correct response: iron-deficiency anemia Explanation: Pica is characterized by a craving for substances that have no nutritional value. Consumption of these substances can be dangerous to the client and her developing fetus. The nurse should monitor the client for iron-deficiency anemia as a manifestation of the client's compulsion to consume soil. Consumption of ice due to pica is likely to lead to tooth fractures. The nurse should monitor for inefficient protein metabolism if the client has been consuming laundry starch as a result of pica. The nurse should monitor for constipation in the client if she has been consuming clay.
A lactose intolerant client is concerned about getting enough calcium in her diet. Which foods could the nurse suggest she include in her diet to increase her calcium intake? Select all that apply. peanuts almonds broccoli molasses carrots
Correct response: peanuts almonds broccoli molasses Explanation: The best source of calcium is milk and dairy products, but for women with lactose intolerance, adaptations are necessary. Additional sources of calcium may be necessary. These may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasses. In additional, encourage the woman to drink lactose-free dairy products or calcium-enriched orange juice or soy milk.
Which increased hormore can contribute to gastric reflux?
Elevated progesterone levels cause smooth muscle relaxation, which can result in relaxation of the cardiac sphincter and reflux of the stomach contents into the lower esophagus. OTC antacids will usually relieve the symptoms but should be discussed with the health care provider first.
