While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? c. Partial abruptio placentae Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.
A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene? c.Lack of the knee-jerk reflex Magnesium sulfate has a depressant effect on the central nervous system; therefore a toxic level will be reflected by the loss of the knee-jerk reflex. The level of consciousness is decreased with excessive magnesium sulfate. There is a deceleration in the respiratory rate with magnesium sulfate toxicity. Development of a cardiac dysrhythmia may be caused by increased potassium, not magnesium sulfate. A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand
moves the fetal head off the cord. What should the nurse anticipate? A. Cesarean birth Immediate birth is necessary to prevent fetal hypoxia and death. Allowing a prolonged labor, inducing labor, or using vacuum extraction in a vaginal birth will increase pressure on the cord, resulting in fetal hypoxia. A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond? A. "It must be difficult to lose this baby that was important to you both." B. "This is nature's way of dealing with babies that may have problems." C. "A curettage will give you a new start. I'll bet you'll get pregnant again soon." D."You must be disappointed, but don't feel guilty. These things sometimes happen." A. "It must be difficult to lose this baby that was important to you both." The response "It must be difficult to lose this baby that was important to you both" acknowledges the loss and the grieving process. It also encourages the expression of feelings. Suggesting that "this is nature's way" minimizes the loss and may reflect the nurse's beliefs. Predicting that another pregnancy will occur soon does not acknowledge the loss and cuts off communication. Guilt feelings were never expressed by the client. The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? A. Cerebral hemorrhage B. Pulmonary edema C. Impending seizures D. Hypovolemic shock D. Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions. A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? A. The client does not have an infection. B. The donor blood is free of bloodborne pathogens. C. The nurse should have worn gloves for self-protection. D. The nurse was skilled enough to prevent exposure to the blood. C. The nurse should have worn gloves for self-protection. The Centers for Disease Control and Prevention (CDC) recommends that gloves be worn when there is the potential for contact with blood or other body fluids. Even if the client does not have an infection, gloves are always worn when exposure to blood or other body fluids is a possibility. All blood is considered potentially infectious. Nurses are required to take precautions that limit exposure; gloves must be worn. A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action? B. Elevating the head of the bed C. Drawing blood for a hematocrit level D. Giving an intramuscular analgesic A. Administering oxygen Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary healthcare provider's prescription. What is the primary responsibility of a nurse teaching the pregnant adolescent? B. Informing her of the benefits of breast-feeding C.Advising her to watch for danger signs of preeclampsia D.Encouraging her to continue regularly scheduled prenatal care D.Encouraging her to continue regularly scheduled prenatal care It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time. The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? A. Prolong the course of labor B. Cause decreased placental perfusion In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true. A client in the thirty-eighth week of gestation exhibits a slight increase in blood pressure. The primary healthcare provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? A. "It increases blood flow to the
fetus." A. "It increases blood flow to the fetus." The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bed rest the blood pressure decreases. The side-lying position does not prevent thrombosis; bed rest and immobility may increase the risk of thrombosis. A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use? A. Number of clots that were
passed D. Amount of blood lost in relation to usual menstrual flow Determining the amount of blood lost in relation to her usual menstrual flow gives the client a familiar gauge with which to estimate the amount of bleeding she is experiencing. The presence of clots does not indicate the amount of bleeding. Changes in fetal activity may indicate a problem, but there is no relationship to the amount of bleeding. Weakness is a subjective symptom and may not reflect blood loss. Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal pregnancy? D. A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder A fallopian tube is unable to contain and sustain a pregnancy to term; as the fertilized ovum grows, there is excessive stretching or rupture of the affected fallopian tube, resulting in pain. At this stage the products of conception are too small to form a mass; the pain is lateral, not centered. The pain is sudden, intense, and knifelike, not prolonged or cramping. Leukorrhea and dysuria may be indicative of a vaginal or bladder infection. The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? B.Perinatal mortality is two to three times more likely in multiple than in single births. C. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. D.Maternal mortality is higher during the prenatal period in the setting of multiple gestation. B.Perinatal mortality is two to three times more likely in multiple than in single births. Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation. During their initial visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? A. Recent history of drug abuse
B. Family history of genetic abnormalities The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next? A. Ambulating the client to promote circulation B. Inserting two small-bore intravenous catheters C. Determining whether the client feels safe at home D.Ensuring that the client has her glasses to ambulate C. Determining whether the client feels safe at home Bruising on the backs of back shoulders and both wrists indicates potential abuse; asking the client whether she feels safe at home will open a dialogue to discuss the possible physical abuse. Whether or not the client admits abuse, the nurse is required to report the finding. A client in preterm labor should have a large-bore intravenous catheter. Ambulation is not appropriate for a client in preterm labor, and bed rest should be maintained. Reporting should not be delayed. A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and is 60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood from the
vagina. The uterus is irritable on palpation and does not relax fully between contractions. What is the initial nursing action? B. Checking the perineum for rupture of membranes C.Changing the underpad and positioning the client on her left side D.Assessing the fetal heart rate, uterine activity, and blood pressure D.Assessing the fetal heart rate, uterine activity, and blood pressure The client should be evaluated for signs of abruptio placentae with an assessment for cessation of uterine activity, fetal heart rate decelerations, and falling blood pressure. The status of fetus and mother must be assessed before any other nursing action (transporting the client for a cesarean birth or changing the underpad and positioning the client on her left side) is taken. Checking the perineum for rupture of membranes is not the priority during this emergency situation. A client's labor has progressed to the point where she is 6 cm dilated; however, the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What other nursing action should be performed at this time? A. Inspecting the perineum B. Preparing for an immediate birth C. Measuring the maternal blood pressure D. Increasing the intravenous (IV) fluid rate A. Inspecting the perineum During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's priority intervention? A. Inserting a urine retention catheter B. Administering oxygen by means of nasal cannula C. Helping the client turn to the side-lying position D. Encouraging the client to pant with her next contraction C. Helping the client turn to the side-lying position Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urine retention catheter is unnecessary; in addition, it requires a primary healthcare provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus. The nurse is caring for a client in her third trimester who is scheduled for an amniocentesis. What should the nurse do to prepare the client for this test? b.Tell her to assume the high Fowler position before the test. c. Encourage her to drink three glasses of water before the test. d. Advise her to take nothing by mouth for several hours before the test. a. Instruct her to void immediately before the test. The client is instructed to void immediately before the test to help prevent injury to the bladder as the needle is introduced into the amniotic sac. The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract. A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? b. Controlling external stimuli c. Having emergency equipment available d.Keeping calcium gluconate at the bedside b. Controlling external stimuli Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures. A 26-year-old G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb (3.6 kg) since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client? A. Mild preeclampsia B. Severe preeclampsia C.Chronic hypertension D.Gestational hypertension A. Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension. During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of large and painful varicose veins. In light of this information, what should the nurse's assessment include? A. Monitoring daily clotting times B. Assessing for peripheral pulses C. Monitoring daily hemoglobin values D.Assessing for signs of thrombophlebitis D.Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency. The nurse
is counseling a pregnant client with type 1 diabetes regarding medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy? b.Antihypertensives c.Pancreatic enzymes d.Estrogenic hormones a. Insulin Usually as pregnancy progresses there are alterations in glucose tolerance and in the metabolism and utilization of insulin. The result is an increased need for exogenous insulin. Antihypertensives are administered only to clients with severe hypertensive preeclampsia. Pancreatic enzymes or hormones other than insulin are not taken by pregnant women with diabetes. Estrogenic hormones are not administered during pregnancy. A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor? A.Scheduling pain medication at regular intervals B. Administering the medication only when the pain is severe C. Avoiding the administration of medication unless it is requested D. Recognizing that less pain medication will be needed by this client compared with other women in labor A. Scheduling pain medication at regular intervals This client will have a lower tolerance for pain and a greater need for pain relief. Larger doses may be needed if pain medication is administered only when the pain is severe. Delays increase anxiety and discomfort, and larger doses will be necessary. Individuals who abuse drugs require more medication than do others because of tolerance to the addictive drug. A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. Which condition does the nurse suspect? A. Mastitis A. Mastitis Because of the presence of generalized symptoms, the nurse should suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced. The nurse is caring for a client
who has had a spontaneous abortion. Which complication should the nurse assess this client for? A. Hemorrhage Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth. The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? A. Calling the primary healthcare provider B. Changing the maternal position C. Obtaining the maternal blood pressure D.Preparing the environment for an immediate birth B. Changing the maternal position The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth. A sonogram performed on a client in the third trimester reveals a low-lying placenta. What should the nurse teach the client that she is at risk for? A.Sharp abdominal pain B.Painless vaginal bleeding C.Increased lower back pain D.Early rupture of membranes B.Painless vaginal bleeding This client's placenta is implanted near the internal cervical os; in the latter part of pregnancy, as the process of effacement occurs, placental separation from the uterus causes painless bleeding. Sharp abdominal pain occurs with abruptio placentae, the premature separation of a normally situated placenta. Increased lower back pain is not specific to a low-lying placenta. Early rupture of membranes is not specific to a low-lying placenta. A client in labor at 39 weeks' gestation is told by the primary healthcare provider that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth? A. Gonorrhea D. Active genital herpes Once the membranes have ruptured, the active herpes infection ascends and can infect the fetus; because herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, Chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacologic. After an incomplete abortion, a client tells the nurse that although her primary healthcare provider
explained what an incomplete abortion was, she did not understand. What is the best response by the nurse? C. "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." A correct and simple definition answers the question and fulfills the client's need to know. Telling the client not to focus on the topic any more denies the client's right to know. The definition of a missed abortion is when the fetus dies but is retained in the uterus for at least 2 months. Telling the client to ask her primary healthcare provider for the answer is an abdication of the nurse's responsibility; the nurse can independently reinforce information and correct misconceptions. A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider regarding breech presentations when caring for this client? A. Severe back discomfort will occur. B. Length of labor usually is shortened. C. Cesarean birth probably will be necessary. D. Meconium in the amniotic fluid is a sign of fetal hypoxia. C. Cesarean birth probably will be necessary. A cesarean birth may be performed when the fetus is in the breech presentation because the risk of morbidity and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation because the buttocks are not as effective as the head as a dilating wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation, because contractions compress the fetal intestinal tract, causing release of meconium. What is the priority nursing intervention during the admission of a primigravida in labor? A. Monitoring the fetal heart rate A. Monitoring the fetal heart rate Determining fetal well-being supersedes all other measures; if the fetal heart rate is absent or persistently decelerating, immediate intervention is required. The health history, including the client's last meal and whether the membranes have ruptured, may be taken once fetal well-being has been established. A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate? A. Hypertension B. Hypoglycemia C. Chilling and shivering D.Bleeding and infection D.Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate, because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes. the nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention at this time? a. Giving a detailed explanation of what may have caused the stillbirth b. Providing the parents the opportunity to say goodbye to their newborn c. Explaining that autopsy is not recommended in the setting of a stillbirth d.Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief b. Providing the parents the opportunity to say goodbye to their newborn Parents should be given the opportunity to say goodbye to a stillborn baby. Because the parents may not think to ask to see the baby, the nurse should provide this opportunity. Giving a detailed explanation of possible causes of the stillbirth is nontherapeutic. An autopsy may be performed when there is a stillbirth. The decision is left to the parents. The procedure can be very important in answering the question "Why?" if there is a chance that the cause of death can be determined. Before the parents leave the hospital, arrangements for follow-up care should be made. This information should be provided immediately, because it can help the parents begin the grieving process. Many hospitals have a team consisting of a social worker, chaplain, and nurse that is called when a stillbirth occurs. A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the
nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life? a. 2:1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4. A pregnant client with a history of preterm labor is at home on bed rest. Which instructions should be included in this client's teaching plan? c. Lie on the side with the head raised on a small pillow Bed rest keeps the pressure of the fetal head off the cervix. The side-lying position keeps the gravid uterus from impeding blood flow through major vessels, thus maintaining uterine perfusion. The Trendelenburg position is used when the cord is prolapsed or the client is in shock. Sitting up in bed increases pressure on the cervix and could lead to further dilation. Assuming the knee-chest position at regular intervals throughout the day may help relieve pressure of the fetus on the cervix; however, it will not enhance uterine perfusion. |
Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal pregnancy
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