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B) Previous cesarean birth C) Placenta previa Rationale: Fetal Maternal-Fetal The blood pressure can be elevated because of pain and is not necessarily a contraindication to vaginal birth until further assessment is completed. Having a history of three spontaneous abortions is not a contraindication to vaginal birth. 1. monitoring fetal status Rationale: Review terms and
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Get faster at matching terms Terms in this set (30)While having blood drawn to test for pregnancy, the client asks the nurse when the chemical they test (hCG) begins to be produced. The most accurate response of the nurse would be: a. 8-12 hours d. 8-10 days. hCG is secreted by the villi at 8-10 days after fertilization. The nurse, working in a gynecologist's office, learns that the client hopes to become pregnant within the next year. The nurse would advise the client to do all of the following except: a. maintain adequate intake of calcium d. increase intake of vitamin c. Adequate intake of of calcium, folic acid, and iron is important to achieve prior to pregnancy, because deficiencies in early stages of pregnancy can adversely affect the fetus. There is no need to increase vitamin c intake when planning pregnancy because excess is excreted and not stored. While caring for a woman who is 16 weeks pregnant, the nurse notes which of the following as being an abnormal change? a. breast enlargement d. increased peristalsis. Peristalsis normally declines due to pressure of the growing fetus on the abdominal contents. The nurse is providing client teaching to the woman who is 38 weeks pregnant. Which of the following would be a key point for the nurse to discuss at this time? a. the importance of taking prenatal vitamins and avoiding alcohol and caffeine d. preparing physically and mentally for childbirth. All of these options are important teaching points, but by 38 weeks of the pregnancy the only one that may need to be reinforced and explained in more detail is the physical and mental preparation for childbirth. The nurse, caring for a newly pregnant woman who is already eating a well-balanced diet, will advise the client to: a. make no changes to her diet b. add one protein and two milk servings. even if eating a well-balanced diet, the expectant mother should add 300 cal a day, which can be covered by the addition of one protein and two servings of milk. This meets the need for increased calcium and protein as well as the need for calories. The nurse, caring for a pregnant woman in the last trimester, will advise the client to sleep on her side primarily for the purpose of: a. relieving pressure on the bladder d. preventing hypotension. The moth should be encouraged to sleep on her side to prevent hypotension; lying supine can cause supine hypotension syndrome. The earliest the nurse will be able to hear the fetal heart tones using a doppler is week: a. 2 c. 10 weeks. The fetal heart beat can be heard with a doppler by 10-12 weeks. The client's last menstrual period began on May 6 and ended May 11. The nurse calculates the client's estimated date of delivery using Naegele's rule as February: a. 6 c. February 13th. Naegele's rule involves taking the first day of the last menstrual period, subtracting 3 months, and adding 7 days. So the correct date using this rule would be February 13th. The nurse, working in an obstetrician's office, receives a call from a woman who is 36 weeks pregnant saying she is experiencing headache, blurred vision, and a lot of swelling. The nurse would advise the client to: a. rest and call back if the symptoms do not stop within 24 hours d. come to the office to be seen this morning. Headache, blurred vision, and marked swelling are indicators of possible preeclampsia. A trip to the emergency department is not neccessary. However, this client should be seen as soon as possible and certainly within 4 hours. The nurse is assisting with the performance of an amniocentesis. Prior to beginning the procedure the nurse's first priority action is to: a. prepare the skin site according to agency policy c. ensure that an informed consent is signed and in the chart An amniocentesis is an invasive procedure that carries risk for the fetus and mother, so a signed informed consent should be obtained before beginning the procedure. All of the other options would be performed after obtaining the consent for the procedure. The nurse advises the pregnant client to do which of the following in order to reduce the risk of toxoplasmosis? a. avoid contact with a cat litter box a. avoid contact with a cat litter box. The pregnant woman should avoid exposure to cat litter because it carries a risk of transmission of toxoplasmosis. When assisting in the care of a client who has mild preeclampsia and is at risk for severe preeclampsia, the nurse would check the urine for the presence of which of the following? a. specific gravity b. protein. Protein in the urine is an indicator of potential preeclampsia. Specific gravity tests urine concentration, not hypertension; glucose indicates diabetic changes; pH indicates an acid-base balance. The nurse recognizes all of the following as factors that contribute to the classification of high risk except: a.
smoking c. residence. Residence alone does not contribute to the calssification of high risk but may combine with other risk factors to worsen the chance of high-risk pregnancy. Smoking, history of preterm labor, and multiple pregnancy are all risk factors. The nurse, talking to a group of high school students, explains that the risks associated with pregnancy increase in pregnant mothers at or under the age of: a. 16 c. 15 years of age. According to research, pregnancy occurring at or below age 15 increases the risk of a negative outcome because growth of the fetus pulls nutrients the teen's body needs for growth. The nurse, caring for a woman with a newly diagnosed pregnancy, explains that it will be necessary to repeat the maternal hemoglobin test at: a. 4 months b. 7 months. Hemoglobin should be rechecked at 7 months of pregnancy to monitor for anemia. The nurse assists the physician in performing a 1-hour glucose screen. The results are 125 mg/dL. The nurse anticipates that the physician will order which of the following? a. insulin
administration c. 100-g oral glucose tolerance test. Results ranging between 110 and 140 mg/dL will require follow-up testing in the form of a 100-g oral glucose tolerance test to confirm the diagnosis of gestational diabetes. The nurse, working in an obstetrician's office, admits a 28-week pregnant client with a history of rheumatic heart disease. The nurse would consider which of the following an important intervention for this client that may not be necessary in other pregnant women? a. measurement of blood pressure b. assessment of breath sounds. The client with a previously weakened heart should be carefully assessed for signs of congenital heart failure. Assessment of breath sounds can be performed independently by the nurse, and the physician may order a chest x-ray if abnormal findings are reported by the nurse. The nurse receives a call from a client who is 26 weeks pregnant reporting discomfort in the lower middle abdomen, urinary frequency, and mild irregular infrequent contractions. The client denies vaginal bleeding or rupture of membranes but says there is a small amount of blood in the urine. The nurse suspects: a. preterm labor b. urinary tract infection. The client is reporting signs of a possible urinary tract infection that could result in preterm labor if rapid intervention is not initiated. The nurse, caring for a client with high-risk pregnancy, recognizes the importance of: a.
frequent fetal and maternal monitoring a. frequent fetal and maternal monitoring. When caring for a client at high risk, one of the most important interventions is frequent monitoring of fetal and maternal well-being so that complications or problems can be caught early and interventions may be performed before further problems develop. The nurse's goal when caring for a client with a high-risk pregnancy is to deliver care that will maintain the pregnancy for as long as possible and to: a. optimize delivery under the best possible circumstances a. optimize delivery under the best possible circumstances. The second goal of caring for a client with a high-risk pregnancy is optimizing delivery under the best possible circumstances. The other options are either not goals or are not within the power of the nurse. Based on the hormonal theory of labor, the nurse anticipates a rise in which of the following to begin a chain of hormonal events that cause labor? a. cortisol a. cortisol Fetal cortisol production increases as the fetus matures and, when sufficient, decreases the placental production of progesterone. This begins the chain of hormonal events that cause labor. The nurse would recognize that the client has experienced lightening when the pregnant woman reports: a. "I can breathe much better" a. "I can breathe much better" Lightening refers to the fetus having descended into the pelvis, relieving pressure on the diaphragm and allowing the mother to breathe more easily and thus feel "lighter". The primary nurse performs a vaginal examination and finds a prolapsed cord. The nurse's priority action will be to: a. give the medication to hasten a vaginal delivery c. make arrangements for an emergency cesarean section. Answer 3 is correct because a prolapsed cord is an emergency situation and requires emergency cesarean section. While waiting for the surgical procedure to begin, it is important to position the client to take pressure off the cord, allowing oxygen and blood to circulate to the fetus. When the fetus is found to be in a vertex presentation, the nurse anticipates the presenting fetal part will be the: a. forehead d. occiput. A vertex presentation indicates the occiput is presenting first with the fetal head in complete flexion. The nurse is caring for a client in labor who complains of feeling faint. The nurse turns the client onto her side in order to have what effect on contractions? a. little or no effect c. increase the intensity. When the mother lies on her side, the contractions will be less frequent, but more intense. The nurse recognizes that the client is in the latent phase of the first stage of labor. This phase is best described as lasting from: a. undilated cervix to a 2 cm dilatation b. onset of contractions to 4 cm dilatation. The latent phase of the first stage of labor is from the onset of contraction until the cervix is dilated 4 cm. The nurse, working on a labor and delivery unit, anticipates active labor for a primigravida will last how long? a. 16-18 hours d. 4-6 hours. The average length of active labor is 4 to 6 hours for the primigravida client. A client in the transition phase of labor irritably tells the nurse not to touch her. The nurse's best action would be to: a. ask for someone else to support the client c. remind the client to focus on relaxation and breathing. It is normal for the client to become irritable and sometimes angry at this stage of labor when the cervix is at least 8 cm dilated but not yet fully dilated at 10 cm. The student nurse asks the primary nurse to explain what the obstetrician meant when telling the client that engagement had occurred. The primary nurse's best response would be to explain that: a. the fetus has now become ballotable b. the presenting part has entered the true pelvis. Engagement occurs when the presenting part enters the true pelvis. At this time, the presenting part is even with or below the ischial spines and the fetus is no longer ballotable. While caring for the client in the fourth stage of labor/delivery, the nurse discovers that the client has saturated two perineal pads during the first hour. What is the nurse's priority action? a. notify the primary nurse immediately a. notify the primary nurse immediately. Any bleeding in excess of one pad saturated per hour in the fourth stage of labor/delivery is considered abnormal and excessive; it should be reported immediately to the nursing supervisor or physician. Sets with similar termsStudy guide for Exam 2 (ch 16 & 27) - OB32 terms deannaallen Maternity exam #2 questions130 terms aryder26 3 OB Chapter 27 - Intrapartum Complications27 terms Rachelle_Karl Sets found in the same folderMother/Baby NCLEX Questions Ch. 54,55,56,5740 terms lelievremele Prenatal Development22 terms tiff_pent NCLEX-Mother Baby76 terms mkp1040 Mother/Baby/Peds stuff for NCLEX13 terms mjk626 Other sets by this creatorCNC CH. 7 NCLEX practice10 terms lelievremele CNC CH. 4 NCLEX practice10 terms lelievremele CNC CH. 2 NCLEX Practice10 terms lelievremele Comprehensive Nursing Care- CH 624 terms lelievremele Other Quizlet sets11-LTM: Explicit vs Implicit Memory16 terms itsalexxaa_ PHY1020 - Exam 1103 terms emma_kerr53 Networking Unit 129 terms mabouelmaali108 CH 317 terms andib3726 Related questionsQUESTION What are the types of incisions? 15 answers QUESTION What hypertensive medications are contraindicated in pregnancy? 15 answers QUESTION Where is progesterone made? What does it do 15 answers QUESTION what are the signs and symptoms of maternal hypotension with decreased placental perfusion? 8 answers Which of the following would be a priority intervention for a client with the prolapsed cord?The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect.
What is the primary nursing action when the umbilical cord is prolapsed?Firstly, call for help – umbilical cord prolapse is an obstetric emergency. It should be managed as follows: Avoid handling the cord to reduce vasospasm. Manually elevate the presenting part by lifting the presenting part off the cord by vaginal digital examination.
In which position would the nurse place the patient who has a prolapsed cord?After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position.
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.
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Which of the following would be a priority intervention for a client with the prolapsed cord quizlet?
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