A Biophysical profile is made up of five parts. What are they? Show
A. Fetal breathing, gross movement, reactive nonstress test, fetal tone, and amniotic fluid B. maintains the endometrial layer for implantation Progesterone is the most important hormone of pregnancy. Its major effects include: (1) suppression of FSH and LH, (2) maintenance of the endometrial layer for implantation of the fertilized ovum and prevention of menstruation, (3) decreased uterine contractility to prevent spontaneous abortion, (4) increased fat deposits, (5) stimulation of development of the lobes, lobules, and ducts in the breast for lactation, (6) relaxation of smooth muscles of the uterus, gastric sphincter, bowel, ureters, bladder, (7) increased respiratory sensitivity to carbon dioxide, stimulating ventilation, (8) suppression of the immunologic response, preventing rejection of the fetus, (9) antagonist to insulin, and (10) retention of sodium. Acts directly on the uterine muscle to stimulate forceful contractions. Used as second line for postpartum hemorrhage. Precautions/interactions: use with extreme caution in clients with hypertension, preeclampsia, heart disease, venoatrial shunts, mitral valve stenosis, sepsis, or hepatic or renal impairment. Side effects: potential vasoconstriction, hypertension, headache. Interventions: continuously monitor BP, assess uterine bleeding and uterine tone. The nurse is assessing a pregnant client at 30 weeks' gestation. Which cardiovascular change should the nurse consider when taking the client's vital signs? C. Cardiac output is increased. Rationale: The cardiovascular change that occurs during pregnancy is an increased cardiac output. Cardiac output begins to increase early in pregnancy and peaks at 25-30 weeks' gestation at 30-50% above pre-pregnancy levels. It generally remains elevated in the third trimester. The heart rate increases to accommodate the additional cardiovascular volume. The plasma volume increases by 50%, while the red blood cell count only increases 25%, resulting in physiologic anemia of pregnancy. A client asks the nurse "When is the most fertile
time of a woman?" Which is the most appropriate answer? A. 12-24 hours after ovulation Rationale: Ova are considered fertile for about 12-24 hours after ovulation. Menstruation usually occurs around day 14 of the menstrual cycle with a normal 28-day cycle. The
nurse is assessing a first-time pregnant client who is 19 weeks after her last menstrual period (LMP). Which finding should the nurse expect to be first noted at this time? B. Fluttering sensation in the abdomen Rationale: Quickening, or the mother's perception of fetal movement, occurs about 18-20 weeks after the last menstrual period (LMP) in a woman pregnant for the first time, but may occur as early as 16 weeks in a woman who has been pregnant before. Quickening is a fluttering sensation in the abdomen that gradually increases in intensity and frequency. Nausea and vomiting, commonly called morning sickness, can occur anytime during the day and occur frequently during the first trimester. Changes in breast tissue, often noted by tenderness and tingling, occur early in the pregnancy. Urinary frequency is experienced in the first trimester as the enlarging uterus presses on the bladder. The nurse is caring for a client who has been diagnosed with physiologic anemia of pregnancy. Which accurately describes the nurse's understanding of physiologic anemia in relation to pregnancy? C. The client has increased plasma. Rationale: A plasma increase of 50% results in physiologic anemia of pregnancy. During pregnancy, the red blood cell (RBC) count increases by 25%, but this is considered decreased secondary to the hemodilution. Because the plasma volume increase (50%) is greater than the RBC increase (25%), the hematocrit, which measures the concentration of RBCs in the plasma, decreases slightly. This decrease is referred to as the physiologic anemia of pregnancy (pseudoanemia). A pregnant client who has been diagnosed with a yeast, Candida, infection says she never had one before. Which is an appropriate response by the nurse? A. "There is a decrease in the acidity of the vaginal fluid, which favors yeast." Rationale: During pregnancy, estrogen causes a thickening of the vaginal mucosa, a loosening of the connective tissue, and an increase in vaginal secretions. These secretions are thick, white, and acidic (pH 3.5dash6.0). The acid pH favors the growth of yeast organisms, thereby making the pregnant woman more susceptible to Candida infection than usual. Blood flow to the vagina is increased during pregnancy but this does not increase the risk of developing a yeast infection. The client asks the nurse how over-the-counter pregnancy tests work. Which hormone should the nurse identify a being recognized by the test to confirm a positive result? B. Human chorionic gonadotropin (hCG) Rationale: The over-the-counter pregnancy tests detect a subunit of hCG to confirm a pregnancy. LH, FSH, and GnRH are not hormones measured to confirm a pregnancy. The hormone hCG is produced by the placenta and prevents involution of the corpus luteum at the end of the menstrual cycle. It also stimulates the corpus luteum to secrete increased amounts of estrogen and progesterone. The hCG levels normally peak in the pregnant client at 10dash22 weeks gestation. There is a rapid decline in the hCG level until 22 weeks gestation. The nurse is using a Doppler device to detect the fetal heart rate. Which fetal heart rate is within the normal range? B. 110-160 beats/min Rationale: The fetal heart rate is between 110 and 160 beats/min and must be counted and compared with the maternal pulse for differentiation. Auscultation of the abdomen may reveal sounds other than that of the fetal heart. The maternal pulse, emanating from the abdominal aorta, may be unusually loud, or a uterine souffle may be heard. The
pregnant client asks the nurse why she must do a glucose tolerance test. Which is an appropriate response by the nurse?
A. "Hormones can alter carbohydrate metabolism and increase maternal glucose levels." Rationale: Hormonal influences may alter carbohydrate metabolism during pregnancy, leading to the development of gestational diabetes mellitus (GDM). Increased maternal glucose levels may cause the fetus to become large for gestational age (LGA), leading to potential complications for mother and fetus during and after delivery. Clients with an existing diagnosis of diabetes mellitus (DM) may develop vascular changes that impair fetal perfusion, resulting in a newborn that is small for gestational age (SGA). Glucose tolerance tests occur during pregnancy to screen for and diagnose GDM. The nurse is working in a free clinic. A pregnant client presents with her first child and states she is feeling the baby move. The client asks how far along she is. Which is the correct response by the nurse? B. 18-20 weeks A
pregnant client asks the nurse, "What is this dark line on my abdomen?" Which response should the nurse provide the client? D. "That is known as
linea nigra and is a common finding during pregnancy." A pregnant client wants to know the cause for bloating and constipation. Which should be the nurse's reply? B. "Increased progesterone causes delayed gastric emptying." The nurse is caring for a client in
the first trimester of pregnancy who is concerned about having sexual intercourse. Which response by the nurse is the most appropriate? D. "As long as there are no complications, intercourse is safe." Rationale: The client can be advised that intercourse is safe anytime during pregnancy as long as there are no complications. Intercourse is not restricted to any specific trimester of pregnancy. The nurse is caring for a pregnant client who expresses concern about the older siblings adjusting to the baby. Which response by the nurse will help promote the older siblings' acceptance of the
baby? C. "You are welcome to bring your children to your prenatal appointment." Rationale: The response that will promote the acceptance of a new baby is, "You are welcome to bring your children to your prenatal appointment." Pregnant women may find it helpful to bring their children to a prenatal visit after they have been told about the expected baby. The children are encouraged to become involved in prenatal care and to ask any questions they may have. They are also given the opportunity to hear the fetal heartbeat, either with a stethoscope or with the Doppler device. This helps make the baby more real to them. The remaining statements do not promote the acceptance of a new baby. The nurse working in a prenatal clinic provides care for clients of diverse cultures. Which action will foster the delivery of more effective, culturally competent care by the nurse? B. Identifying personal biases and prejudices Rationale: Identifying personal biases and prejudices will foster the delivery of more effective, culturally competent care by the nurse. Religious and cultural beliefs should be critically examined, not merely identified. Sharing personal cultural beliefs is not appropriate when caring for a client. The services of a professional interpreter are used when a language barrier exists. The nurse is caring for an obstetrical client who expresses feeling stressed over the impending delivery of the baby. Which nursing intervention is most appropriate for the client's situation? C. Encourage the expression of concerns. Rationale: The nursing intervention most appropriate for the client who communicates feeling stressed over the impending delivery of her baby is to encourage the client to express her concerns. Notifying social services is unwarranted. Providing relaxation techniques and reassuring the client that everything will be fine does not address the client's concerns. The nurse is preparing to discharge an adolescent client who is 2 days' postpartum.
Which question by the nurse addresses the developmental task of the client? D. "Do you plan on returning to school?" The nurse is caring for a primigravida who is 38 years of age. Which factor should the nurse understand is associated with delaying
childbearing? A. The incidence of later marriage Rationale: The incidence of later marriage is associated with the delay in childbearing. Infertility and psychosocial issues are factors in delaying pregnancy. There are more, not minimal, birth control options available. The nurse is caring for a 48-year-old obstetrical client. Which factor may be of most concern for the client based on the age of the client? A. Childrearing Rationale: The factor that may be of most concern to the client is the actual childrearing. The ability to deal with the needs of an older child as the client ages is of great concern. The older client is generally healthy, has established a career, and is financially secure. When caring for an older woman who is pregnant, which factor should the nurse most anticipate as affecting the care and outcome of the pregnancy? C. Medical procedures Rationale: The factor that will affect the care and outcome of the pregnancy of an older woman is the increased medical procedures that are offered. Medical procedures such as amniocentesis, ultrasound, and antepartum testing are more likely to be performed for an older woman. Chronic illness, postpartum recovery, and surgical procedures are not primary factors that are likely to affect the care and outcome of a pregnancy. Which factor may more significantly impact an older woman experiencing a
spontaneous abortion compared to a younger woman? A. Anxiety over the ability to conceive again Rationale: The factor that significantly impacts an older woman who has experienced a spontaneous abortion is the anxiety over the ability to conceive again. The anxiety is due to the "biological clock," or the remaining time left to conceive again. Financial loss is not directly associated with a spontaneous abortion. Women of all ages that have experienced a loss of pregnancy experience grief. The loss of maternal identity is experienced by women of different ages and is based on specific circumstances such as infertility and the inability to conceive. The nurse is reviewing the histories of four new prenatal clients. Which maternal risk factor indicates the need for
antenatal testing? A. Twin gestation pregnancy Rationale: Obstetrical factors, such as multifetal gestation and previous fetal loss, are indicators for antenatal testing. Demographic factors such as age younger than 17 or older than 35 years may indicate the need for antenatal testing. Mothers who are vegans may have special nutritional needs, but this factor alone does not indicate the need for fetal antenatal testing. A maternal history of depression is not an indicator for antenatal testing. The nurse is caring for an obstetrical client during her first visit who states that she is experiencing nausea and vomiting. The nurse should identify which hormone as responsible for this change? B. Human chorionic gonadotropin (hCG) Rationale: Increased levels of hCG are attributed to the client's nausea and vomiting. During pregnancy, estrogen enlarges the uterus, and causes breast tenderness and nasal stuffiness. Progesterone is essential for maintaining the pregnancy. Human placental lactogen assists in maintaining the fetus's glucose levels. Human chorionic gonadotropin preserves the corpus luteum. The nurse is caring for a client who is at 10 weeks' gestation and experiencing "some gastrointestinal problems." Which symptom should the nurse anticipate specifically in the client? B. Diarrhea Rationale: Ptyalism, or increased salivation, may occur during pregnancy. Urinary frequency is a genitourinary change that occurs during pregnancy. Diarrhea is an abnormal symptom and is not an expected change in the gastrointestinal system during pregnancy. The nurse is caring for a client who is 36 weeks' gestation and diagnosed with gestational diabetes mellitus. Which maternal complication will the client be monitored for? A. Preeclampsia Rationale: Preeclampsia or eclampsia occurs more often in pregnant women with diabetes, especially when diabetes-related vascular changes already exist. Clients with gestational diabetes are 4?5 times more likely to develop gestational hypertension. Gestational diabetes does not place the client at an increased risk for anemia or preterm labor. The client with diabetes is at risk for hydramnios. The nurse is teaching smoking cessation to a newly
pregnant client who still smokes. Which fetal complication of cigarette smoking should the nurse include? C. Prematurity Rationale: The nurse will teach the client about the risk of prematurity associated with smoking. Postterm gestation, congenital anomalies, and newborns who are large for gestational age are not risk factors associated with maternal smoking. A client with type 2 diabetes mellitus requiring insulin has just discovered that she is pregnant. The nurse is teaching the client about insulin requirements during pregnancy. Which guideline should the nurse provide? B. "Insulin requirements increase during the last two trimesters." Rationale: Maternal insulin requirements fluctuate throughout pregnancy; decreasing during the first trimester, then increasing during the second and third trimesters. During the second half of pregnancy, fetal growth accelerates and there is an increased utilization of glucose by the fetus. In response to this, the placental hormone, human placental lactogen (hPL), creates insulin resistance in the maternal tissues to have sufficient glucose available for the fetus. This increased insulin resistance may result in an increase in maternal insulin requirements. During labor, insulin requirements diminish due to the increased maternal energy expenditure. The nurse is caring for a client at 32 weeks' gestation who asks, "Why do I waddle when I walk?" Which
explanation by the nurse provides the client with accurate information? B. "A hormone causes the pelvic joints to relax." Rationale: The joints of the pelvis relax due to hormonal influences, resulting in a waddling gait. A change in the center of gravity results in lordosis. A low calcium intake will not result in a waddling gait. The changes in the client's gait are due to hormones, not an underlying musculoskeletal disorder. The nurse is caring for a client who is at 38 weeks' gestation who is positive for group B streptococcus (GBS). Which information should the nurse provide the client? C. "You will be given an antibiotic treatment during labor." Rationale: The client who is GBS positive will be treated with an antibiotic during labor. GBS is one of the major causes of early onset neonatal infection that can be transmitted by vertical transmission from the mother during birth or by horizontal transmission from colonized nursing personnel or colonized babies. If the maternal infection is not resolved prior to delivery, IV antibiotics will be prescribed during labor. Treatment is not delayed until after birth. The client will not be prescribed a prophylactic antibiotic throughout the pregnancy. The nurse is caring for a pregnant client
beginning her second trimester of pregnancy. Which question is the most appropriate for the nurse to ask? A. "How are you getting relief from your lower back pain?" Rationale: The nurse's role in the second trimester includes providing teaching about the common discomforts of pregnancy, such as lower back pain. Questions about childbirth classes and birth plans are appropriate questions for later in the pregnancy, during the third trimester. Testing for Group B strep occurs during the third trimester. A pregnant client asks the nurse when the 1-hour oral glucose tolerance test (OGTT) will be performed to screen for gestational diabetes. Which response by the
nurse is the most accurate? B. "You will be screened between 24 and 28 weeks' gestation." The 1-hour OGTT screening test for gestational diabetes is performed at between 24 and 28 weeks' gestation. All clients are screened for gestational diabetes. The nurse is caring for a client who asks, "Why do I need an ultrasound and all of these tests while I am pregnant?" Which response by the nurse provides the most appropriate explanation for antenatal testing to the client? D. "Tests such as ultrasounds can help screen for birth defects." Rationale: Antenatal testing helps ascertain fetal well-being, growth, and development during the prenatal period and allows for screening and detection of congenital abnormalities. Antenatal testing does not ensure a baby will be healthy. The statements, "These tests ensure your baby is healthy," "I will ask the doctor to explain these tests to you later," and "Ultrasounds are painless and your insurance will pay for it" do not address the client's question. The nurse is caring for a client who is at 28 weeks' gestation and diagnosed with gestational diabetes. The client expresses fear that the baby will not be healthy. Which response by the nurse provides the necessary reassurance to the
client? C. "We will help you to modify your diet to keep your blood sugar at normal levels to maintain a healthy pregnancy and baby." Rationale: The response by the nurse that provides the most reassurance to the client is, "We will help you to modify your diet to keep your blood sugar at normal levels to maintain a healthy pregnancy and baby." Gestational diabetes mellitus is controlled by diet and exercise. Referring the client to the midwife negates the client's concern for her baby. Telling the client to be prepared for complications is not good therapeutic communication, nor does it provide reassurance to the client. Gestational diabetes can have a significant effect on the pregnancy and may be associated with serious outcomes for the fetus, which include intrauterine growth restriction, macrosomia, symptomatic neonatal hypoglycemia, and fetal demise if left untreated. The nurse is caring for a
couple attending their first prenatal visit. The client states, "I have had trouble with anemia in the past." Which response by the nurse reflects the most appropriate plan of care in managing the pregnancy? B. "You will be instructed to take iron and folic acid throughout the pregnancy." Rationale: The goal of healthcare for the client is to prevent anemia so the client will be instructed to take an iron supplement and a folic acid supplement. If the results indicate the client has iron deficiency anemia or megaloblastic anemia caused by a folate deficiency, further treatment may be required. Folic acid supplementation also prevents neural tube defects. All pregnant clients are encouraged to take prophylactic supplementation of iron and vitamins in addition to their diets. Iron and folate supplementation is not deferred for laboratory results. The nurse is caring for a client who has had a positive pregnancy test. The nurse reviews the client's history and notes the client smokes half a pack of cigarettes a day. Which information should the
nurse include in the plan of care? A. Refer her to a smoking cessation program. Rationale: The information that is important to include in the plan of care for the client that smokes half a pack of cigarettes a day is a referral to a smoking cessation program. Chewing gum is not a replacement for smoking cessation. A 12-step rehabilitation program is for drug or alcohol abuse. Any smoking adversely affects the fetus. The nurse caring for a pregnant client with diabetes mellitus interprets the results of the client's nonstress test (NST) as nonreactive. Which intervention should the nurse anticipate? B. Arrange for a biophysical profile. Rationale: If the NST is nonreactive a biophysical profile may be performed. A biophysical profile is indicated when there is a risk of placental insufficiency or fetal compromise. Indications for a biophysical profile include material diabetes mellitus and nonreactive NST. Oxytocin is used to induce or augment labor in a pregnant client. It is not standard practice to administer oxygen in this case. There is no indication of fetal distress in the case presented, so it is not reasonable to anticipate a cesarean birth delivery. The nurse is caring for a client who is at 28 weeks' gestation and diagnosed with heart disease. Which condition should prompt the nurse to contact the healthcare provider immediately? A. Increased dyspnea at rest Rationale: Increased dyspnea at rest must be reported immediately because it may be an indication of congestive heart failure. Mild ankle edema and weight gain of 1 pound a week are expected physical findings during the third trimester. Emotional stress on the job can increase cardiac demand and should be reported only if the client experiences symptoms such as palpations or an irregular heart rate. The nurse caring for a client who is at 35 weeks' gestation is planning to teach the client about the premonitory signs of labor. Which statement is appropriate to include in the teaching? A. "You may notice that you breathe easier when the baby drops down into your pelvis." Rationale: The client's session should include the statement, "You may notice that you breathe easier when the baby drops down into your pelvis." As lightening occurs, the pregnant client may experience easier breathing. As the pregnancy continues, the client may experience increased dependent edema, backache, leg pain, urinary frequency, and vaginal discharge. Bloody show is the loss of the blood-tinged cervical mucus plug. Vaginal bleeding is abnormal and should be reported to the healthcare provider. The nurse is caring for a client who is at 31 weeks' gestation and admitted for preterm labor. The client expresses concern for her baby and missing work. Which is a nursing
priority? A. Providing emotional support Rationale: Based on the client's concerns, the nurse's priority is to provide the client emotional support. Clients experiencing preterm labor may have a difficult time coping with their concerns regarding the diagnosis. The nurse's role does not include restricting family visitors or contacting the client's employers. Concern for the unborn baby is a normal response and is not an indication for antianxiety medication. The nurse is providing a prenatal class instruction on different exercises that can be done to prepare for childbirth. Which exercise should the nurse include that specifically helps reduce back strain? B. Pelvic tilt Rationale: The pelvic tilt can reduce back strain as it strengthens the abdominal muscles. Kegel exercises strengthen the pelvic floor muscles. Tailor sitting is used to stretch the inner thighs. Partial sit-ups strengthen abdominal muscle tone. The nurse is conducting a dietary assessment for a pregnant adolescent. Assessment of the dietary intake of which nutrient should be a
priority? A. Calcium Rationale: Inadequate intake of calcium is frequently a problem for this age group. Adequate calcium is important to continue to support the growth and calcium maintenance of the adolescent as well as the growth and development of the fetus. Vitamin K and magnesium are not found to be deficient in the adolescent. Vitamins B6, A, and D are found to be deficient in this age group, not vitamin B12. A client at 39 weeks of gestation is demonstrating signs of labor. Which hormonal action is responsible for the onset of labor? A. Increase in estrogen Rationale: Theory suggests that increased estrogen levels allow the myometrium to become more sensitive to oxytocin. This sensitivity allows for the initiation of uterine contractions. In labor, progesterone levels decrease, not increase. Theory suggests that decreased progesterone levels increase myometrial contractility. Research shows an association between prostaglandin-producing agents stored in the fetal membranes and the onset of labor. Corticosteroids are increased during pregnancy and labor. A pregnant client is admitted to
the hospital in premature labor. Which assessment finding should the nurse anticipate? B. Cervical dilation Rationale: Signs of preterm labor include cervical dilation, abdominal pain, diarrhea, lower back pain, pelvic pressure, and increased vaginal discharge. Headaches, elevated blood pressure, and decreased fetal movement are not clinical manifestations of preterm labor. The nurse is assessing a client at 38 weeks of gestation. Which premonitory signs may occur before the onset of labor? (Select all that apply.) A. Braxton Hicks contractions Rationale: Lightening occurs as the fetus descends or drops down into the maternal pelvis. Bloody show usually occurs within 48 hours of the onset of true labor, and is also associated with the loss of the cervical mucus plug. Braxton Hicks contractions, or false labor, occur as the body is priming itself for the impending labor and delivery. Prior to the onset of labor, women generally have a surge of energy. Which sign is associated with the
impending delivery of the placenta? (Select all that apply.) A. Lengthening of the umbilical cord Rationale: Delivery of the placenta usually takes place within 30 minutes of birth. Signs that the placenta is about to deliver include increased pain with contractions, lengthening of the umbilical cord, and a change in shape of the uterus from a disk to a globe. A client is experiencing a hypertonic uterine contraction pattern. Which time frame correctly describes how often the contractions are occurring? C. Every 2 minutes or less Rationale: Tachysystole, also known as hypertonic contractions, is defined as spontaneous or stimulated uterine activity that is excessive in nature. It is characterized by contractions occurring every 2 minutes or less. The other time frames listed are not characteristic of uterine tachysystole. A
client is told that her pelvic diameters are "slightly" contracted. The client asks the nurse how this will impact the birth plan. Which response by the nurse is the most appropriate? B. "You will have a trial of labor first; a cesarean delivery will occur if the trial is not successful." Rationale: With only a minimal contracture of the pelvis, a trial of labor is indicated, and, if not successful, a cesarean birth will be performed. Introducing the concept of the trial of labor but mentioning the possibility of a cesarean birth if the trial is not successful is a positive and informative response. Telling the client that she can deliver vaginally or will have to have a cesarean birth is inaccurate information. The nurse cannot assume that the client will not be successful with a trial of labor. Making a statement to a client such as, "It might be possible to have a vaginal delivery, but I would count on a cesarean delivery," is not therapeutic and is inaccurate information. The nurse is admitting a client for an induction of labor. The client asks if it would just be easier
to have a cesarean birth because she is afraid of the pain. Which response from the nurse is most appropriate? B. "Due to the risk factors a cesarean birth has, it is only recommended if the benefits clearly outweigh the risks." Rationale: The most appropriate response to the client is, "Due to the risk factors a cesarean birth has, it is only recommended if the benefits clearly outweigh the risks." Cesarean births have a higher risk of bleeding, infection, and injury to other structures. Future pregnancy may be complicated by uterine scar separation and placenta accreta. Furthermore, risks to the mother increase with each consecutive surgery. The other statements provide inaccurate information to the client. The nurse is admitting a client at 39 weeks of gestation scheduled for a trial of labor after a previous cesarean birth who reports having uncomfortable contractions for a whole day and sleeplessness at night.
The client's cervix is 3 cm, 50% effaced, and the baby is at -2 station. The baby's heart rate is 144 beats/min and contractions are palpable every 5-7 minutes. Which describes the nurse's anticipated action? A. Encouraging fluids by mouth Rationale: This client is in the latent phase of the first stage of labor. During this time, it is normal for cervical dilation to progress at less than 1 cm every 2 hours. A prolonged latent phase may be treated with therapeutic rest and hydration. It is not necessary to augment the client's labor with oxytocin or prepare for a cesarean delivery. Rupturing membranes at a -2 station places the client at risk for a prolapsed cord. The nurse is preparing to care for a client in the second
stage of labor. Which comfort measures should the nurse implement in the plan of care? B. Provide sips of fluids or ice chips. Rationale: Sips of fluids or ice chips may be used to provide moisture and relieve dryness of the mouth. Applying cool, not warm, cloths to the face and forehead may help to cool the woman involved in the intense physical exertion of pushing. The client is not encouraged to ambulate in the second stage of labor, but instead to rest in between pushing. The nurse and support person can assist the woman into a pushing position with each contraction to further conserve energy. Between contractions, the woman should be assisted into a comfortable position. The nurse is caring for a low-risk
client in the latent phase of labor. The client states, "I am hungry and would like something light to eat." Which describes the nurse's understanding of fluid and nutritional intake during labor? B. Fluids and foods may be offered. Rationale: It is unnecessary to restrict intake in any way for the client that is low risk in the latent phase of labor. Furthermore, evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. The nurse auscultates the fetal heart rate (FHR) with a Doppler for a client in active labor, and determines that it is 90 beats/min. Which action should the nurse identify as a
priority? A. Repositioning the mother laterally The nurse is caring for a client who is undergoing a labor induction
and reports feeling uncomfortable. The client declines analgesia, instead preferring to walk and change positions frequently. The nurse notes frequent gaps in the fetal heart rate tracing and sections showing wide disparities in baseline fetal heart rate. Which action should the nurse take? D. Reposition the ultrasound transducer. Rationale: The nurse will reposition the ultrasound transducer to obtain a continuous fetal heart rate tracing. A nonreassuring fetal heart rate pattern cannot be identified with an intermittent tracing. A suspected fetal arrhythmia may not be noted with an intermittent tracing. It is not necessary to reposition the mother on her left side to improve uteroplacental perfusion unless the tracing is nonreassuring. The nurse is caring for a client who will have an amniotomy performed. The client states to the nurse, "I know my healthcare provider explained this earlier, but I am not sure what the procedure is." How should the nurse respond? D. "The provider will rupture the amniotic membrane to stimulate your labor." Rationale: The nurse's response to the client's question is, "The provider will rupture the amniotic membrane to stimulate your labor." An amniotomy is the artificial rupture of the amniotic membrane (AROM) to augment labor. Stripping the membranes involves the healthcare provider inserting a gloved finger into the internal os of the cervix and rotating it to separate the membranes from the lower uterine segment. Telling the client to ask the provider when they arrive is not a therapeutic response. Identifying the fetal station during a vaginal examination enables the provider to determine the relationship of the fetus to the maternal pelvis. The nurse is caring for a client in the second
stage of labor who is at +3 station, but has not made further progress over the last 3 hours. The nurse notifies the healthcare provider. Which action should the nurse anticipate the healthcare provider to order? B. Setting up for an instrument-assisted delivery Rationale: A client who has made no progress in the second stage of labor and is at +3 station may require an instrument-assisted delivery. Perineal hygiene and emotional support will not facilitate the delivery. A full bladder can impede delivery, but there is no indication that this is the case at this time. A nurse performs a cervical exam on a client with ruptured membranes and palpates a loop of umbilical cord. Which should be the nurse's initial action? C. Pushing the presenting part away to avoid cord compression Rationale: The nurse's initial action is to apply pressure on the presenting part to avoid fetal cord compression. An amnioinfusion will not resolve the issue of a prolapsed cord. Discontinuing the oxytocin administration is appropriate, but it is not the nurse's initial action. Providing oxygen to the mother may help fetal oxygenation status; however, it is not the initial nursing intervention. The nurse is caring for a client going into the fourth stage of labor. Which is a priority nursing assessment during this stage? A. Fundal assessment Rationale: During the fourth stage of labor, the nurse's priority is a fundal assessment. The fundus should be firm and midline about midway between the symphysis pubis and umbilicus. During the fourth stage of labor, nurses can expect changes in the maternal vital signs. The nurse should expect to perform assessments every 15 minutes × 4, then every 30 minutes × 2, then every hour until stable. The nurse will expect moderate vaginal drainage (lochia rubra). The woman may report feeling chilly, thirsty, hungry, and tired. The nurse is caring for a client in the second stage of labor and at a +5 station. The client appears overwhelmed and is experiencing perineal burning. Which action is a priority for the nurse at this time? C. Offering encouragement and support Rationale: During the second stage of labor the client requires encouragement and support. The client at a +5 station is an imminent delivery. Providing sips of water, applying extra blankets for warmth, and frequent perineal cleansing are not priorities at this time. The nurse is performing an
admission assessment on a client in early labor. Which question should the nurse ask to evaluate the client's emotional state? C. "What are your expectations of this pregnancy?" Rationale: The woman's psyche or emotional state can affect her response to the labor and delivery process. The nurse can evaluate the client's emotional state with the question, "What are your expectations of this pregnancy?" Asking the client about likes or dislikes or baby names is not a direct assessment of the client's emotional state. Encouraging the client to walk is not an assessment of an emotional state. The nurse is caring for a client who is 4 cm dilated. The healthcare provider performs an
amniotomy to augment the client's labor. Which correctly describes the nurse's role during an amniotomy? B. Assessing the amniotic fluid Rationale: The nurse's role during an amniotomy is to document the characteristics of the amniotic fluid as well as monitor the fetal heart rate (FHR). The characteristics of amniotic fluid that are noted include its color, odor, and quantity. Perineal care is important but not the most important thing to do during an amniotomy. The Bishop score is not necessary prior to an amniotomy for a client who is 4 cm dilated. If an epidural is in place prior to an amniotomy, decreasing the dose is not within in the scope of practice for nursing and is not necessary. The nurse providing care for a client in active labor notes a
gradual decline in the fetal heart rate, beginning with the onset of a contraction and followed by a gradual return to baseline by the end of the contraction. Which is the most appropriate nursing response? C. Continuing monitoring Rationale: The most appropriate response by the nurse is to continue monitoring the client. Which position increase cardiac output in the obstetrical client with cardiac disease?A change from the supine to a lateral recumbent position between contractions (basal conditions) increases maternal cardiac output by ≈22% and decreases heart rate by 6%.
Which of the following position fetal position is considered ideal and is most conducive to a birth that requires few interventions during delivery process quizlet?Full flexion means the smallest diameter of the fetal head is presenting to the cervix. This position is considered to be ideal and is most conducive to a healthy delivery that requires fewer interventions.
Which pregnant client would be at increased risk of placenta previa?Placenta previa is more common among women who: Have had a baby. Have had a previous C-section delivery. Have scars on the uterus from a previous surgery or procedure.
Which postpartum complication would the nurse monitor for a client with Hydramnios?The complications associated with polyhydramnios are premature rupture of the membranes, life threatening umbilical cord compression, preterm labor, abruption placentae, fetal distress and fetal death. Continuous monitoring and the manual withdrawal of excessive amniotic fluid, may be indicated.
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Which position increases cardiac output in the obstetrical client with cardiac disease quizlet
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