UncomplicatedPregnancy, Labor, Childbirth, and thePostpartum Period

96問 • 1年前

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At her first visit to the prenatal clinic, a client tells the nurse she is ambivalent about continuing the pregnancy. Why does the nurse conclude that the client is experiencing a crisis?

Pregnancy is a period of change and adjustment to change.

A pregnant woman who is at term is admitted to the birth- ing unit in active labor. She is excited about the anticipated birth because she has three sons and the amniocentesis indi- cated that she will have a girl. Which factor in the client’s history alerts the nurse that the newborn will be at risk for a complication?

She used NSAIDs for frequent sinus headaches.

A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy does the embryo become a fetus. How should the nurse respond?

During the eighth week of the pregnancy

A client at 35 weeks’ gestation asks a nurse why her breathing has become more difficult. How should the nurse respond?

“Your diaphragm has been displaced upward.”

A nurse at the prenatal clinic examines a client and deter- mines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation does this occur?

12th week of pregnancy

What information should a nurse include when counseling a pregnant client about human immunodeficiency virus (HIV) testing? Select all that apply.

Risks of passing the virus to the fetus, Meaning of positive or negative test results, Emotional, legal, and medical implications of test results

At what time during prenatal development should the nurse expect the greatest fetal weight gain?

Third trimester

A client tells the nurse that the first day of her last menstrual period was July 22, 2010. What is the estimated date of birth?

April 29 2011

What information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?

Physical and emotional changes resulting from pregnancy

A nurse is caring for a client during an ultrasonogram. What parameters does the nurse expect to be used when determining pregnancy dates?

Crown to rump measurement until 11 weeks

What change does a nurse expect in a client’s hematologic system during the second trimester of pregnancy?

An increase in blood volume

During a physical in the prenatal clinic the client’s vaginal mucosa is observed to have a purplish discoloration. What sign should the nurse document in the client’s clinical record?

Chadwick

What does a nurse explain to a pregnant client about the cause of her physiologic anemia?

Plasma volume increases.

The nurse reviews the blood test results of a client who is at 24 weeks’ gestation. Which finding should be reported to the health care provider?

Hemoglobin: 10.8 g/dL

At her first prenatal visit, a client says to the nurse, “I guess I’ll be having an internal examination today.” What is the nurse’s best response?

“Have you ever had an internal examination done before?”

A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, what does the nurse docu- ment about the client’s obstetric history?

G5 T2 P1 A1 L4

A nurse is assessing a pregnant client during the third trimester. What clinical finding is an expected response to the pregnancy?

Shortness of breath on exertion

A pregnant woman reports nausea and vomiting during the first trimester of pregnancy. An increase in which hormone should the nurse explain is the precipitating cause of the nausea and vomiting?

Chorionic gonadotropin

During a client’s first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The client states that her mother told her she should restrict her salt intake. What is the nurse’s best response?

“Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet.”

A pregnant client uses a computer continuously during her working hours. This has implications for her plan of care during pregnancy. What should a nurse recommend?

“Try to walk around every few hours during the workday.”

A client at her first prenatal clinic visit is at 6 weeks’ gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond?

“What activities does your job entail?”

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?

Different cultural groups favor different essential nutrients.

A primigravida in her 10th week of gestation is concerned because she has read that nutrition during pregnancy is important for the growth and development of the fetus. She wants to know something about the foods she should eat. What should be the nurse’s initial response?

Ask her what she has eaten over the last three days.

A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she can add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply.

Black and pinto beans, Enriched bread and pasta

A client at 8 weeks’ gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is dimin- ished by:

compression by the enlarging uterus.

While caring for a pregnant client and her partner, a nurse suspects domestic violence. Which assessments support this suspicion? Select all that apply.

Woman has injuries to the breasts and abdomen, Partner answers questions that are asked of the woman., Woman has visited the clinic several times in the last month.

A client at 10 weeks’ gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief?

“Eat dry crackers before arising.”

What should a nurse suggest to a pregnant client that might help overcome first-trimester morning sickness?

“Eat protein before bedtime.”

What should a nurse include in nutritional planning for a newly pregnant woman of average height weighing 145 pounds?

An increase of 300 calories per day

A client is concerned about gaining weight during pregnancy. What should the nurse explain is the cause of the largest amount of weight gain during pregnancy?

Fetal growth

A client at 7 weeks’ gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomit- ing and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the:

third month.

A pregnant client is being prepared for a pelvic examination. She states that she is always tired and feels sick to her stomach, especially in the morning. What is the nurse’s best response?

“Let’s discuss ways to resolve these common problems.”

During a prenatal examination, a nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for developing:

acute hemolytic anemia.

What is the best advice a nurse can give to a pregnant woman in her first trimester?

“Avoid drugs, and refrain from smoking and ingesting alcohol.”

During a routine visit to the prenatal clinic, a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should respond, “The heart rate is:

usually rapid and is in the expected range.”

When involved in prenatal teaching, a nurse should inform clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase?

Production of estrogen

A client who is 28 weeks into her second pregnancy is expe- riencing increasing edema in the lower extremities. The nurse advises rest with the legs elevated and provides dietary instructions. What else should the nurse suggest?

The foods selected do not need to have a low salt content.

What recommendation should a nurse give to clients who have fluid retention during pregnancy?

Elevate the lower extremities.

A 36-year-old multigravida who is at 14 weeks’ gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, “What does the alpha-fetoprotein test indicate?” The nurse bases a response on the knowledge that this test can detect:

neural tube defects.

A client is scheduled for a nonstress test in the 37th week of gestation. A nurse explains the procedure. Which statement demonstrates that the client understands the teaching?

“If the heart reacts well, my baby should do okay when I give birth.”

A client in the 18th week of pregnancy is scheduled for ultrasonography. What instruction should the nurse give the client?

“Don’t urinate for at least 3 hours before the test.”

A nurse is teaching a primigravida about how she can identify the onset of labor. What clinical indicator of labor would necessitate the client to call her health care provider?

Membranes rupture or contractions are 5 to 8 minutes apart.

A nurse teaches a pregnant woman to avoid lying on her back during labor. What information about the result of lying in the supine position is the basis for the nurse’s teaching?

Placental perfusion is decreased.

A 42-year-old client has an amniocentesis during the 16th week of gestation because of concern about Down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?

Neural tube defect

During the postpartum period, a client tells a nurse she is having leg cramps. Which foods should the nurse encourage the client to eat?

Cheese and broccoli

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs?

When planning to become pregnant

A pregnant client asks the clinic nurse how smoking will affect her baby. What information about cigarette smoking will influence the nurse’s response?

The resulting vasoconstriction affects both fetal and maternal blood vessels.

A client who is at 12 weeks’ gestation tells a nurse at the prenatal clinic that she has severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. With what disorder is this frequently associated?

High levels of chorionic gonadotropin

A nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care supervision throughout pregnancy. Which cardiovascu- lar compensatory mechanisms should the nurse explain will occur? Select all that apply.

Increased blood volume, Increased cardiac output, Enlargement of the heart

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious during this period and asks a nurse, “Do you think it is best for me to leave, since I don’t seem to be doing my wife much good?” What is the nurse’s best response?

“This is hard for you. Let me try to help you coach her during this difficult phase.”

A nurse is caring for an obese client in early labor. The anesthesiologist discussed several types of analgesia/ anesthesia with the client and recommended one. The client requests clarification before signing the consent form. Which type did the anesthesiologist recommend?

Epidural anesthesia

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse’s immediate reaction?

Turn the client on her side.

A nurse is caring for a primigravida during labor. At 7 cm dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?

Butorphanol (Stadol)

A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain?

Acts on opioid receptors to reduce pain

At a prenatal visit a client who is at 36 weeks’ gestation states that she is having uncomfortable irregular contractions. What should the nurse recommend?

“Walk around until they subside.”

How does the nurse identify true labor as opposed to false labor?

Cervical dilation is progressive.

Why should a nurse teach pregnant women the importance of conserving the “spurt of energy” before labor?

Fatigue may influence the need for pain medication.

A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?

Auscultating the fetal heart

A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and 3 cm dilated. The fetal head is at +1 station. In what area of the client’s pelvis is the fetal occiput?

Below the ischial spines

After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler be placed to best auscultate fetal heart tones?

Below the umbilicus on the right side

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, “I cannot stand this a minute longer.” What does this behavior indicate to the nurse caring for her?

She is entering the transition phase of labor.

A nurse assesses the frequency of a client’s contractions by timing them from the beginning of a contraction:

to the beginning of the next contraction.

A nurse observes a laboring client’s amniotic fluid and decides that it is the expected color. What description of amniotic fluid supports this conclusion?

Straw-colored, clear, and contains little white specks

What is a common problem that confronts the client in labor when an external fetal monitor has been applied to her abdomen?

Intrusion on movement

A client’s membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. A nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?

Change the client’s position.

A client’s membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?

Auscultate the FHR.

The membranes of a client who is at 39 weeks’ gestation have ruptured spontaneously. Examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival?

Introduce the staff nurses to the couple and try to make them feel welcome.

A pregnant woman at 39 weeks’ gestation arrives in the triage area of the birthing unit, stating she thinks her “water broke.” What should the nurse do first?

Check the vaginal introitus for the presence of the umbilical cord.

A client is admitted to the birthing unit in active labor. What should the nurse expect after an amniotomy is performed?

Progressive dilation and effacement

A primigravida who is at 40 weeks’ gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm dilation and the presenting part at −1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse do next?

Provide the client with comfort measures used for women in labor.

When monitoring the FHR of a client in labor, the nurse identifies an elevation of 15 beats more than the baseline rate of 135 beats/min lasting for 15 seconds. How should the nurse document this event?

An acceleration

A client and her partner are working together during the woman’s labor. The client’s cervix is now dilated 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that would alleviate the client’s discomfort during contractions?

Deep breathe slowly.

Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor?

Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia.

How should a nurse direct care for a client in the transition phase of the first stage of labor?

Help the client to maintain control.

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?

Blowing

When a client’s legs are placed in stirrups for birth, the nurse confirms that both legs are positioned simultaneously to prevent:

trauma to the uterine ligaments.

A nurse is caring for a primigravida during labor. What does the nurse observe that indicates birth is about to take place?

Perineum begins to bulge with each contraction.

For what complication should a nurse monitor a client when an oxytocin (Pitocin) infusion is used to induce labor?

Uterine tetany

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?

Push with her glottis open.

A laboring client is to have a pudendal block. What should a nurse teach the client about the effects of the pudendal block?

She will not feel an episiotomy.

After a client gives birth, what physiologic occurrence indi- cates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

Appearance of a sudden gush of blood

A multigravida has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time?

Halfway between the symphysis pubis and the umbilicus

A client in labor begins to experience contractions 2 to 3 minutes apart that last about 45 seconds. Between contrac- tions the nurse identifies a fetal heart rate of 100 beats/min on the internal fetal monitor. What is the next nursing action?

Notify the health care provider.

A client is bleeding excessively after the birth of a neonate. The health care provider orders fundal massage and prescribes an IV infusion containing 10 units of oxytocin (Pitocin) at 100 mL/hr. A nurse’s evaluation of the client’s responses to these interventions is BP: 135/90 mm Hg; uterus: boggy at 3 cm above the umbilicus and displaced to the right; perineal pad: saturated with bright red lochia. What is the nurse’s next action?

Assess for a distended bladder.

A nurse is evaluating the effectiveness of fundal massage on a postpartum client 3 hours after giving birth. An IV infusion of 10 units of oxytocin (Pitocin) is infusing at 100 mL/hr. Her blood pressure is 135/90, the uterus is boggy at 3 cm above the umbilicus and displaced to the right, and her perineal pad is saturated with lochia rubra. What should the nurse do next?

Assist the client to the bathroom.

A primigravida who is at 35 weeks’ gestation is diagnosed with hydramnios. For what should the nurse assess the newborn?

Esophageal atresia

A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do, and anyway holding babies during feedings spoils them. What is the nurse’s best response?

“You seem concerned about time. Let’s talk about it.”

A primipara has just given birth at 37 weeks’ gestation. What should the nurse do to help promote the attachment process between the mother and her newborn?

Encourage continuous rooming-in.

A multigravida of Asian descent weighs 104 pounds, having gained 14 pounds during the pregnancy. On her second postpartum day, the client’s temperature is 100.2° F. She is anorectic and rarely gets out of bed. What should the nurse do?

Encourage the family to bring in special foods preferred in their culture.

At 9 PM visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention?

Encourage the sister to participate in care as much as the client wishes.

Three weeks after giving birth, a client develops a deep vein thrombophlebitis of the left leg and is admitted to the hos- pital for bed rest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?

Continuous infusion of heparin

A nurse teaches a postpartum client how to care for her episiotomy to prevent infection. Which behavior indicates that the teaching was effective?

She washes her hands whenever a perineal pad is changed.

A nurse observes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period?

It may indicate retention of urine with overflow.

When palpating a client’s fundus on the second postpartum day, a nurse identifies that it is above the umbilicus and displaced to the right. What does the nurse conclude?

The bladder has become overdistended.

A nurse examines a client who had a cesarean birth. It is 3 days since the birth and the client is about to be discharged. Where does the nurse expect the fundus to be located?

3 fingerbreadths below the umbilicus

A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response in language the client will understand?

Peripheral vasomotor activity is promoted.

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Kyla Angelique Son · 19問 · 1年前

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