A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2013. Using Naegele's rule, the nurse determines the estimated date of birth as: Show
C June 26, 2014 A nurse midwife is performing an assessment of a
pregnant client and is assessing the client for the presence of ballottement. Which of the following would the nurse implement to test for the presence of ballottement? D Initiating a gentle upward tap on the cervix A nurse is assisting in
performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. A Uterine enlargement A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: A Any bleeding, such as in the gums, petechiae, and purpura. These are signs of DIC which signify bleeding. A prenatal nurse is providing instructions to a group of pregnant client regarding measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further instructions? C "I need to drink unpasteurized milk only." A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the
Preeclampsia and the need to notify the physician? C The client complains of a headache and blurred vision A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is
caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? C Respiratory rate of 10 BPM Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus. Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a newborn infant and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? A Being affected by Rh incompatibility A Being affected by Rh incompatibility After the first four months of
pregnancy, the chief source of estrogen and progesterone is the: A Placenta The nurse recognizes that an expected change in the hematologic system that occurs during the 2nd trimester of pregnancy is: C An increase in blood volume A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is: C G5 T2 P1 A1 L4 A 26-year old multigravida is 14 weeks' pregnant and is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does the alpha-fetoprotein test indicate?" The nurse bases a response on the knowledge that this test can detect: C Neural tube defects A 21-year old client, 6 weeks' pregnant is diagnosed with hyperemesis gravidarum. This excessive vomiting during pregnancy will often result in which of the following conditions? B Electrolyte imbalance A nurse is caring for a client in labor. The
nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? D The cervix is dilated completely A nurse in the labor room is caring for a client in the active phases of labor. The nurse is
assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: C Administer oxygen via face mask A nurse is caring for a client in labor who is receiving
Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? B A fetal heart rate of 90 beats per minute A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period. A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? B Continuous electronic fetal monitoring A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A Place the client in Trendelenburg's position A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected
diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? C Uterine tenderness/pain A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A Prepare the client for an ultrasound C Obtain equipment for a manual pelvic examination Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia. The physician asks
the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: C To the beginning of the next contraction Four hours after a difficult labor
and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: D Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby. A postpartum nurse is
preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: B Every 15 minutes during the first hour and then every 30 minutes for the next two hours. A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? C Changes in vital signs Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues. A
nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? D "I need to stop breastfeeding until this condition resolves." In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics. The
nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A "Nausea and vomiting can be decreased if I eat a few crackers before arising" Which of the following would be concerning during assessment of breastfeeding? A The attachment of the baby to the breast. D The baby's lips smacking Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who's smacking his lips isn't well attached and can injure the mother's nipples. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? C The fetus isn't in distress at this time. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? B Abruptio placentae A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? D "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." A new mother is having trouble breastfeeding her newborn. The
child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
C Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself (C). After such a time out, breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated. Barbiturates are usually not given for pain relief during active labor for which of the following reasons? C They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor. When PROM occurs, which of the following provides evidence of the nurse's understanding of the client's immediate needs? B PROM removes the fetus most effective defense against infection PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client's most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM. Which of the following is the nurse's initial action when umbilical cord prolapse occurs? B Place the client in a knee-chest position in bed Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage? D More than 500 ml The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first? D Determine the amount of lochia A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage. Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do? A Call the assessment data to the physician's attention D Recognize this as normal first period of reactivity The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. The infant's assessment data reflect normal adaptation. Thus, the physician does not need to be notified and oxygen is not needed. The data do not indicate the presence of choking, gagging or coughing, which are signs of excessive secretions. Suctioning is not necessary. The post term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? A Respiratory problems The fetal heart rate is checked following rupture of the bag of waters
in order to: B Determine if cord compression followed the rupture After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head. The mechanisms involved in fetal delivery is B Descent, flexion, internal rotation, extension, external rotation To ensure that the baby will breath as soon as the head is delivered, the nurse's priority action is to A Suction the nose and mouth to remove mucous
secretions A Suction the nose and mouth to remove mucous secretions At what APGAR score at 5 minutes after birth should resuscitation be initiated? A 1-3 Which action would the nurse take after observing a prolapsed cord?When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm.
What is the priority intervention when a cord prolapse has occurred?Umbilical cord prolapse is an acute obstetric emergency that requires immediate delivery of the baby. The route of delivery is usually by cesarean section. The doctor will relieve cord compression by manually elevating the fetal presentation part until cesarean section is performed.
Which is the focus of nursing care for a laboring client when the umbilical cord suddenly prolapses and protrudes from the vagina?What is the priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord protruding from the vagina? The fetus's life is in jeopardy and a cesarean birth must be performed immediately. The cord is never handled because it may go into spasm and block the fetal blood supply.
Which of the following should be the nurses priority intervention when making a plan of care for an expectant mother experiencing dystocia?The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus.
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Which of the following is the nurses initial action when umbilical cord prolapse occurs Quizlet
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