3. Notify the health care provider (HCP). Show
The fetal heart rate (FHR) depends on gestational age and ranges from 160 to 170 beats/ minute in the first trimester, but slows with fetal growth to 110 to 160 beats/ minute near or at term. At or near term, if the FHR is less than 110 beats/ minute or more than 160 beats/ minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified. Test-Taking Strategy: Note the strategic word, "priority." Also note the FHR and that the client is at 38 weeks of gestation. Review terms and
definitions Focus your studying with a path Get faster at matching terms The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. 3 - 2, 0, 0, 1 Sets with similar termsThe nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and expects which finding? 2. 30 cm During the second and third trimesters, fundal height in centimeters approximately equals the fetuses age in weeks. The 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. Which are probable signs? Select all that apply. 1. Ballottement The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix), Chadwick's sign (violet coloration of the cervix, vagina, and vulva), ballottement (rebounding of the fetus against the examiner's fingers), Braxton Hicks contractions, and positive pregnancy test. A pregnant client is
seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding which nursing action is most appropriate? 3. Inform the client that these contractions are common and may occur throughout the pregnancy The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instructions should the nurse provide for the client? 4. A C-section will be necessary if vaginal lesions are present at the time of labor The nurse is reviewing the
record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic? 1. A softening of the cervix A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? 2. July 26, 2015 The HCP is
assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 4. Initiate a gentle upward tap on the cervix Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 4. 14 and 18 The nurse is performing an assessment of a primigravida who is being evaluated in a clinic
during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up? 3. Fetal heart rate of 180 bpm The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who
was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document? 2. G2T1P0A0L1 The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 3. An informed consent needs to be signed before the procedure An informed consent needs to be obtained before the procedure. After the procedure the client is instructed to rest, but may resume light activity after the cramping subsides. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 2. "The vaginal discharge may be bothersome, but it is a normal occurrence" Leukorrhea begins during the first trimester. The client should not wear tampons because of the risk for infection, the client should wear panty liners and change them frequently. The nurse has performed a nonstress test on a pregnant client and is reviewing
the fetal monitor strip. The nurse interprets the test is reactive. How should the nurse document the finding? 1. Normal A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within the normal range (120-160 bpm) with good long term variability. In addition, two or more fetal heart rate accelerations of at least 15 bpm must occur, each with a duration of at least 15 seconds, in a 20 minute interval. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The healthcare provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document the findings? 1. A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test 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. A pregnant client
tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? 3. Hemoglobin 9.1 g/dL Pica often leads to iron deficiency anemia, resulting in a decreased hemoglobin level. The lab results in options 1, 2, and 4 are normal for the pregnant client. A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell the client that which exercise is safest? 1. Swimming Non weight bearing exercises are preferable to weight bearing exercises. A health care provider has prescribed transvaginal ultrasonography for the client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel" Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in the lithotomy position and a probe, encased in a disposable cover and coated with gel is inserted into the vagina. The procedure takes about 10-15 minutes. 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 instruction? 4. "I should wear knee high hose, but I should not leave them on longer than 8 hours" Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing impedes venous return from the lower legs and places the client at risk for developing varicosities. 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? 2. "Bend your foot toward your body while extending the knee when the cramps occur" 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 the apply. 2. Pregnancy needs to be avoided for 1-3
months 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? 2. "I need to lie flat on my back to perform the procedure" The
nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? 4. "I should apply heat packs to the hemorrhoids to help them shrink" Measures to provide relief from hemorrhoids include avoiding constipation and straining during bowel movements, applying ice packs, gently replacing hemorrhoids into the rectum, using stool softeners, ointments, or sprays as prescribed, and assuming certain positions to relieve pressure. The nurse is providing instructions to a client in the first trimester of pregnancy regarding
measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 2. Wash the breasts with warm water and keep them dry The nurse is describing
cardiovascular system changes the 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 Between 14-20 weeks gestation the pulse rate increases about 10-15 bpm, which then persists to term. 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? 4. "I should avoid eating foods that produce gas and fatty foods" The nurse is providing instructions to a pregnant client with HIV regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle feed your newborn" The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider? 4. The client complains of a headache and blurred vision A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their initial period of
grief? 1. "What can I do for you?" The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus.
Which statement made by the client indicates a need for further teaching? 3. "I should avoid exercise because of the negative effect on insulin production"
The nurse is performing an assessment on a pregnant client with severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 4. Evidence of bleeding, such as in the gums, petechiae, and purpura Severe preeclampsia can trigger DIC because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported immediately. The nurse in a maternity unit is reviewing the client's records. Which client would the nurse identify as being the most risk for developing DIC? 3. A gravida II who has just been diagnosed with dead fetus syndrome Dead fetus syndrome, severe preeclampsia, and hemorrhage (500 mL is not considered hemorrhage) are considered a risk factors for DIC. A home care nurse is
monitoring a pregnant with gestational HTN who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic sign of preeclampsia? Select all that apply. 1. Proteinuria The nurse is assessing a pregnant client with
type 1 DM about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first Insulin needs decrease in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. A pregnant client reports to a health care clinic complaining of loss of appetite, weight loss, and fatigue.
After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Myobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 4. Isoniazid plus rifampin will be required for 9 months The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 4. "I should drink adequate fluids an increase my intake of high fiber foods" The valsalva maneuver should be avoided in a client with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. The clinic is performing a psychosocial assessment of a client who has been told that she
is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting HIV? 1. A client has a history of IV drug use The nurse in a maternity unit is providing
emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group" The nurse evaluates the ability of a hepatitis-B positive mother to provide safe bottle-feeding to her newborn. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 4. The mother washes and dries her hands before and after self care of the perineum and asks for a pair of gloves before feeding A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal
bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding the management of care. Which statement made by the client indicates a need for further teaching? 2. "I will maintain strict bed rest throughout the remainder of the pregnancy" The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? 3. Uterine hyperstimulation A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted? 2. Respirations of 10 breaths per minute Signs of magnesium toxicity relate to the CNS depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and sudden decline in FHR, maternal heart rate, and blood pressure. The nurse is monitoring a client in preterm labor who is receiving IV magnesium sulfate. The nurse should monitor for which adverse effects of this medication?
Select all the apply. 1. Flushing Adverse effects of magnesium sulfate include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which statement indicates a need for further teaching? 1. "I will flush the eyes after instilling the ointment" Eye prophylaxis protects the newborn against gonorrhea and chlamydia. A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which
medication? 2. Betamethasone (Celestone) Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered between 28-32 weeks if labor can be inhibited for 48 hours. Methylergonovine is prescribed for a women to treat postpartum
hemorrhage. Before administration, what is the priority nursing assessment? 2. BP The nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 2. Intratracheal An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory distress occurs? 1. Naloxone RhoGAM is prescribed for a client after
delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 4. Being affected by Rh incompatibility Methylergonovine
is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical record? 4. Peripheral vascular disease Methylergonovine is an ergot alkaloid, which are contraindicated in client with significant CVD, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan? 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta" A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding
the ductus venosus? 3. Connects the umbilical vein to the inferior vena cava The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery. A pregnant client tells the clinic nurse that she want to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks gestation because of which factor? 1. The appearance of external genitalia The nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the fetal heart rate is 174 bpm. On the basis of this finding, what is the priority nursing assessment?
3. Notify the HCP The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tubes for 3 days, what is the nurse's best response? 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus" The nurse instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all
the apply. 1. Allows for fetal movement A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate? 2. "Do you plan to have any other children" The nurse should include which statement to a pregnant client found to have a gynecoid pelvis? 2. "Your type of pelvis is most favorable for labor and birth" An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate. Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 3. It is the way the baby gets food and oxygen A 55-year-old male
client confides in the nurse that he in concerned about his sexual function. What is the nurses best response? 2. "Please share with me more about your concerns" Which of the following factors would the nurse suspect as predisposing a client to placenta previa?Which of the following factors would the nurse suspect as predisposing a client to placenta previa? Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.
What are the functions of amniotic fluid select all that apply quizlet?Select all that apply. The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin; allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for the fetus.
Which is the following measures assist in reducing breast tenderness quizlet?Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses will cause discomfort (especially on test days, even if you're not pregnant. Yo.). A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia.
Which is the priority nursing action for the client with an ectopic pregnancy?Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy? Question 1 Explanation: For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority.
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