The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? Show
A. Clear, dark amber colored, and containing shreds of mucus Using the 5-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks. A. G4, T2, P1, A1, L2 B. G4, T1, P2, A1, L1 C. G4, T1, P1, A1, L3 D. G4, T2, P1, A1, L1
A pregnant client has two children at home, the first born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Which is the correct summary of her obstetric history using the GTPAL system? A. G5, T1, P1, A2, L2 B. G4, T2, P2, A1, L4 C. G2, T3, P3, A2, L1 D. G3, T2, P1, A3, L3 ANS: B Growth of the fetus, body changes, and nutritional guidance Rationale: A & D- Information on infant care, travel to the hospital, signs of labor, signs of preeclampsia, and relaxation breathing techniques are appropriate in the last trimester. C- Interventions for nausea and vomiting, urinary frequency, and anticipated care are appropriate for the first trimester. A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments? Report the findings because the client needs immediate intervention. Document the results because they are expected at 20-weeks' gestation. Record the findings in the medical record because they are not within the norm but are not critical. Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus. Document the results because they are expected at 20-weeks' gestation. Rationale A client tells the nurse that the first day of her last menstrual period was July 22. What is the estimated date of birth (EDB)? May 7 April 29 April 22 March 6 Rationale Which information should the nurse include in the discharge teaching of a postpartum client? The prenatal Kegel tightening exercises should be continued. The episiotomy sutures will be removed at the first postpartum visit. She may not have a bowel movement for up to a week after the birth. She should schedule a postpartum checkup as soon as her menses returns. The prenatal Kegel tightening exercises should be continued. Rationale How does the nurse determine when true labor and not false labor is present? Cervical dilation is evident. Contractions stop when the client walks around. The client's contractions progress only when she is in a side-lying position. Contractions occur immediately after the membranes rupture. Cervical dilation is evident. Rationale A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. How should the nurse respond? "These accelerations are a sign of fetal well-being." "These accelerations indicate fetal head compression." "Umbilical cord compression is causing these accelerations." "Uteroplacental insufficiency is causing these accelerations." "These accelerations are a sign of fetal well-being." Rationale When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse's action be to confirm that the membranes have ruptured? Take the client's oral temperature. Test the leaking fluid with Nitrazine paper. Obtain a clean-catch urine specimen. Inspect the perineum for leaking fluid. Test the leaking fluid with Nitrazine paper. Rationale Which statements regarding the involution process are correct? Select all that apply. Involution begins immediately after expulsion of the placenta. Involution is the self-destruction of excess hypertrophied tissue. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a nonpregnant state after birth. Involution may be caused by retained placental fragments and infections. Involution begins immediately after expulsion of the placenta. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a nonpregnant state after birth. A client in active labor has requested epidural anesthesia for pain management . The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation? It is the policy of the institution to provide 2 bags of lactated Ringer solution. There is a risk of hypotension, and the large amount of IV fluid reduces this risk. Giving the large amount of IV fluid is a means of hydrating the client when she is unable to drink. The client must be given 500 mL of fluid to ascertain that the line is patent. There is a risk of hypotension, and the large amount of IV fluid reduces this risk. Rationale As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? Turn her onto her left side Elevate the head of the bed Place her feet on several pillows Give her oxygen via a face mask Turn her onto her left side Rationale The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? Prolong the course of labor Cause decreased placental perfusion Lead to transient episodes of hypertension Interfere with free movement of the coccyx Cause decreased placental perfusion Rationale A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed? Diminished bloody show Increased and more variable fetal heart rate Less discomfort with contractions Progressive dilation and effacement Progressive dilation and effacement Rationale During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent? Fetal hypoxia Perineal lacerations Carpopedal spasms Maternal hypertension Fetal hypoxia Rationale During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? First Second Prodromal Transitional First A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond? "Your lower rib cage is more restricted." "Your diaphragm has been displaced upward." "Your lungs have increased in size since you got pregnant." "The height of your rib cage has increased since you got pregnant." "Your diaphragm has been displaced upward." Rationale A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What should the nurse do first? Give her the bedpan. Change the bed linens. Inspect her perineal area. Take an oral temperature. Inspect her perineal area. Rationale While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats per minute that lasts 15 seconds. How should the nurse document this event? An acceleration An early increase A sonographic motion A tachycardic heart rate An acceleration Rationale A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram? Empty her bladder. Avoid eating for 8 hours. Take a laxative the night before the test. Increase fluid intake for 1 hour before the procedure. Increase fluid intake for 1 hour before the procedure. Rationale Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? Reposition the client from supine to left lateral. Increase the intravenous flow rate from 125 to 150 mL/hr. Administer oxygen at a rate of 8 to 10 L/min by way of face mask. Assess the maternal blood pressure for a systolic pressure below 100 mm Hg. Reposition the client from supine to left lateral. Rationale A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part? Entering the vagina Floating within the bony pelvis At the level of the ischial spines Above the level of the ischial spines At the level of the ischial spines Rationale The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching? "The fetus keeps growing throughout pregnancy." "The fetus may be underweight if it's exposed to smoke." "The fetus gets nutrients from the amniotic fluid." "The fetus gets oxygen from blood in the placenta." "The fetus gets nutrients from the amniotic fluid." Rationale On a routine prenatal visit, what is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? Quickening Palpitations Pedal edema Vaginal spotting Quickening Rationale What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? Scant alba Scant rubra Moderate rubra Moderate serosa Moderate rubra Rationale When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? There is a slow rate of involution. There are retained placental fragments. The bladder has become overdistended. The uterine ligaments are overstretched. The bladder has become overdistended. Rationale A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action? Notifying the healthcare provider Resuming continuous fetal heart monitoring Continuing to monitor the maternal vital signs Documenting the fetal heart rate as an expected response to contractions Notifying the healthcare provider Rationale A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take? Discontinuing the test because the pattern is within the normal range Encouraging the client to drink more fluids to decrease the fetal heart rate Notifying the primary healthcare provider and preparing for an emergency birth Recording this nonreassuring pattern and continuing the test for further evaluation Discontinuing the test because the pattern is within the normal range Rationale What common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? Intrusion on movement Inability to take sedatives Interference with breathing techniques Increased frequency of vaginal examinations Intrusion on movement Rationale A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? Kidney defects Cardiac anomalies Neural tube defects Urinary tract anomalies Rationale A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? Increasing the infusion rate Checking for a distended bladder Continuing to perform fundal massage Continuing to assess the blood pressure Checking for a distended bladder Rationale The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what? Estimate fetal age Detect hydrocephalus Rule out congenital defects Approximate fetal linear growth Estimate fetal age Rationale The electronic fetal monitor displays contractions every 2 minutes and lasting 95 seconds. What is the nurse's highest priority intervention at this time? Stop the oxytocin (Pitocin) infusion. Administer oxygen at 8 to 10 L/min. Increase the main line fluid delivery rate to 150 mL/hr. Prepare the client for insertion of an intrauterine pressure catheter. Stop the oxytocin (Pitocin) infusion. Rationale At which point during a human pregnancy does the embryo become a fetus quizlet?When is the conceptus called a fetus and when is it called an embryo? It is called an embryo for the first 7 weeks. At the 8th week, it is called a fetus, which means "young in the womb".
Which recommendation would the nurse make to a pregnant client who sits almost continuously during her working hours quizlet?A tachycardic FHR is one faster than 160 beats per minute. Which recommendation would the nurse make to a pregnant client who sits almost continuously during her working hours? "Try to walk around every few hours during the workday."
Which statement indicates that a pregnant client requires further teaching about fetal growth and development quizlet?The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching? "The fetus gets nutrients from the amniotic fluid."
For which reason would the nurse encourage a client to void during the first stage of labor quizlet?During labor the nurse encourages the client to void periodically. The nurse knows that an overdistended urinary bladder during labor can do what? (An overdistended urinary bladder prevents the uterus from contracting after birth; contraction of the uterus constricts blood vessels, preventing hemorrhage.
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Which direction would the nurse give a client in preparation for ultrasonography at the end of her first trimester quizlet?
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