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68 C Ph 2 test 9
Test 9
| Question | Answer |
|---|---|
| What is female gametogenesis called? | Oogenesis |
| What is conception? | Human fertilization occurs when the sperm penetrates an ovum and unites with it |
| What is the pre-embryonic period? | The first two weeks after conception |
| What is formed by the union of the sperm and ovum? | Zygote |
| What is an example of a teratogenic agent? | Any drug, virus, irradiation that the mother is exposed to can cause malformation of the fetus (example of virus=Rubella) |
| What is the embryonic period? | Extends from beginning of the 3rd week to the 8th week after conception |
| What is the amniotic sac? | A sac made up of the chorion and the amnion that contains the fetus and amniotic fluid |
| Identify 3 parts of the umbilical cord | 2 arteries, one vein, and Wharton's jelly |
| Which fetal circulatory structure is responsible for blood entering the heart from the vena cava and directed across the right atrium to the left atrium? | The foramen ovale |
| Which twins originate with one fertilized ovum? | Monozygotic twins |
| What are some possible complications from a multigestational pregnancy? | Spontaneous abortions, prematurity, uterine over distention, birth defects, and maternal anemia |
| Which is more accurate in determining pregnancy, a blood or urine test? | Blood test |
| Amenorrhea is often the first sign of pregnancy, what are some other signs? | Nausea, breast changes, fatigue, urinary changes, and feeling the baby moving |
| Name the methods to determine the EDD? | Nagele's rule, a wheel, an electronic calculator for this purpose, physical exam, ultrasound, or a combination |
| What type of history is obtained from the woman on her first prenatal visit? | A complete past and present history, including obstetric history |
| What is the recommendation for exercise during pregnancy? | Most activities that the woman is involved in prior to the pregnancy can be continued, but should be discussed with her provider if there are any doubts or concerns |
| List some ways to prevent constipation | Maintain fluid intake of at least 8 glasses of water Eat a balance diet with whole grains, fruits, and vegetables Encourage her to respond promptly to the urge to defecate |
| List some ways to prevent backaches | Wear low heeled shoes Teach proper posture and body mechanics Allow for frequent rest periods |
| Name four key nutrients in pregnancy | Protein, iron, calcium, and folic acid |
| How much weight should a normal woman gain during pregnancy? | 25-35 pounds |
| What are some of the psychological implications that occur in pregnancy during the second trimester? | Narcissism and introversion Body image Changes in sexuality |
| What is the impact on grandparents to pregnancy? | Prospective grandparents have different reactions to a woman's pregnancy |
| How can you communicate with a patient that does not speak your language? | Use an interpreter, NOT friends or family |
| Is it okay for a pregnant woman to follow cultural traditions? | Yes, as long as they don't have a potential for harm |
| What is a major area of concern for the delayed pregnancy? | High risks to both mom and fetus |
| What is a major area of concern for the teen pregnancy? | Friends, family, social services |
| List some methods of childbirth preparation | Dick-Read Method, Bradley Method, and Lamaze Method |
| Name some types of childbirth classes appropriate for the entire family | Sibling and grandparent classes, breastfeeding classes, and infant care classes |
| What are goals of childbirth education? | To help the parents become knowledgeable consumers, take an active role in maintaining health during pregnancy and birth, and learn coping skills to help adjust to pregnancy, childbirth and parenting |
| What are the areas typically discussed in prepared childbirth classes? | Review of reproductive A&P; physical and emotional changes during pregnancy and childbirth; fetal growth and development; nutrition; routine aspects of prenatal hygiene and exercise; danger signs during pregnancy; explanation of birthing processes |
| Why is it important to encourage early prenatal care? | To achieve a healthy pregnancy for both mother and fetus |
| What are the 2 broad categories that complications during pregnancy are grouped into? | -Those that are related to the pregnancy and are not seen at other times (GDM) -Those that could occur at any time but when they occur concurrently with pregnancy may complicate its course (Chronic DM) |
| What is the most common indication for an amniocentesis during the third trimester? | Assess if fetal lungs are mature enough to adapt to extrauterine life |
| How can a nurse facilitate communication with a client undergoing fetal diagnostic procedures? | By providing clear, simple explanations of what the test measures and its purposes |
| How can we help families cope? | By helping them set realistic goals and encouraging them to express their concerns |
| What is it called when a female is pregnant has excessive nausea vomiting, which significantly hinders nutritional status and causes electrolyte and metabolic imbalances? | Hyperemesis Gravidarum |
| Name a nursing intervention that can be provided to a person with hyperemesis gravidarum | Encourage bland, low fat diet, avoid negative comments when serving food, intake and output, daily weights **monitor urine for ketones, meals q 2-3 hours** |
| List appropriate nursing care for a patient experiencing a bleeding disorder of early pregnancy | Assess for shock, pain, and provide emotional support |
| List signs and symptoms of hypovolemic shock | Fetal heart changes, rising weak pulse, rising respiratory rate, shallow irregular respirations, falling blood pressure, decreased urine output, pale skin, cold clammy skin, faintness, and thirst |
| What is the premature separation of a placenta that is normally implanted? | Abruptio placenta |
| What occurs when the placenta develops in the lower part of the uterus? | Placenta previa |
| Name two nursing interventions used in both placenta previa and placenta abruptio | Standard vital signs and fetal monitoring |
| Which disorder of pregnancy has painless, profuse, bright red bleeding? | Placenta previa |
| Why is the patient placed on her left side while on bed rest? | It helps improve blood flow to the placenta and more effectively providing oxygen and nutrients to the fetus |
| What compound is present in urine with a person who has preeclampsia? | Protein |
| What drug is administered to moms who are Rh negative? | Rhogam |
| What is the disease that occurs when anti Rh antibodies cross the placenta and destroy fetal erythrocytes? | Erythroblastosis fetalis |
| List some examples of teratogens that are harmful to the fetus: | Infections, radiation, drugs, chemicals |
| What are some of the fetal effects of FAS? | CNS impairment, facial features, growth restriction |
| What are some of the maternal effects of tobacco use? | Decreased placental perfusion, anemia, PROM, preterm labor |
| What are the effects of IPV during pregnancy? | Multiple injury sites, particularly of the abdomen, face, and breast; increased risk of contracting STDs and HIV; late prenatal care; missed appointment; vaginal bleeding; UTI; low weight gain, anemia, and use of alcohol and illicit drugs are increased |
| What is the nurse's role in assisting with the prevention of domestic violence? | Identify those at risk and provide woman with appropriate interventions such as assisting with a safety plan, affirm that she is not to blame, and providing referrals |
| Define drug Category A | No evidence of risk to the fetus exists |
| What are the other FDA Pregnancy categories? | Category B=Animal repro studies have not demonstrated risk to fetus C=Animal repro studies have shown an adverse effect, but no studies done on humans D= + evidence of fetal risks, but benefits may outweigh risks X= + evidence, risks outweigh benefits |
| What is the goal for a pregnant woman with diabetes? | Maintain a normal blood glucose level |
| What are some of the potential fetal and neonatal effects of an infant born to a mom with diabetes in pregnancy if the diabetes is not controlled? | Congenital malformations that are most commonly associated with preexisting diabetes include neural tube defects, caudal regression syndrome (the legs are short and cardiac defects may occur) |
| What are the most common cardiac problems during pregnancy? | Rheumatic heart disease, congenital heart defects, and/or mitral valve prolapse |
| Anemia during pregnancy is defined as? | Hemoglobin concentrations of less than 11g/dl in the first and third trimester, and less than 10.5g/dl in the second trimester |
| TORCH stands for? | Toxoplasmosis, other diseases (hepatitis), rubella, cytomegalovirus, and herpes simplex virus |
| What disease can be transmitted via cat feces? | Toxoplasmosis |
| True or false: Contact precautions is the method applicable to AIDS/HIV mothers | False |
| What is the primary advantage of the traditional hospital setting? | It is safe: All emergency equipment and personnel are readily available |
| Why is it cultural knowledge important? | It provides a framework to assess and care for the woman and her family as individuals. A woman's anxiety level rises when she does not understand what is happening to her or what is being said |
| When should a woman report to the birthing facility? | Contractions: 5 mins apart for 1 hour for first labor. 10 mins apart for 1 hour for 2nd and subsequent labors Ruptured membranes Bleeding other than bloody show Decreased fetal movements |
| What are powers? | Involuntary uterine contractions which cause the cervix to open and that propel the fetus downward through the birth canal |
| How are dilation and effacement estimated? | Effacement is the thinning of the cervix, described as a percentage of the original length of the cervix from 0-100%. Dilation is the widening of the opening of the cervix and canal from 1-10cm. Estimated on sterile vaginal exams |
| True labor is characterized by? | Progress and consistency |
| What is an L&D admission assessment? | A focused assessment performed before the broader database assessment to determine the condition of mother and fetus and whether birth is imminent |
| What are Braxton-Hicks contractions? | Irregular contractions that begin during pregnancy and intensify as full term approaches. While some may be intense, they remain irregular and do not dilate the cervix |
| What is precipitate labor? | Labor in which birth occurs within 3 hours of its onset |
| When evaluating fetal heart rate patterns what information is recorded on the monitor paper? | FHR is recorded on the upper strip of the paper, contraction pattern is recorded on the bottom strip |
| When does the end of labor pain occur? | With the birth of the baby |
| How does childbirth pain differ from other types of pain? | The pain is self-limiting and rapidly declines after birth. The pain of labor ends with the birth of a baby |
| What application of nonpharmacologic techniques can be applied during labor? | Relaxation, cutaneous stimulation, hydrotherapy, mental stimulation, and breathing techniques |
| What is the goal of second stage breathing? | To assist the mother to respond to her urge to push rather than pushing when her cervix is completely dilated, but she does not have the urge |
| What are s/s of hyperventilation? | Dizziness, tingling of hands and feet, cramps and muscle spasms of hands, numbness around nose and mouth, blurring of vision |
| What general nursing interventions can be used with a laboring mother? | Promoting relaxation, reducing outside sources of discomfort, reducing anxiety and fear, and helping the woman use nonpharmacological techniques |
| What are some advantages of nonpharmacological interventions? | Does not harm the mother, does not slow labor if they provide adequate pain control, no risk for allergy or adverse drug effects |
| What are some limitations of nonpharmacological interventions? | Should be rehearsed before labor begins; many women will not have adequate pain control by using these methods alone |
| When can pharmacologic techniques begin? | They can begin once the patient is admitted to labor and delivery |
| If an epidural or subarachnoid block is given, what should the nurse observe for? | Hypotension |
| If a dural puncture occurs, what might happen? | A relatively large amount of spinal fluid leaks from the hole and may result in a severe headache |
| List some advantages of pharmacologic methods | Helps reduce pain, helps woman relax and work with contractions |
| What is a risk of an episiotomy? | Infection and blood loss |
| What is an amniotomy? | Artificial rupture of the membranes (amniotic sac) by using a disposable plastic hook (Amnihook). Referred to as AROM |
| What is macrosomia? | A large fetus, generally weighing over 4000 gm (8 lb 13 oz) or more at birth; head may be so large it can't mold to the pelvis |
| What is a prolapsed umbilical cord? | The cord slips downward after the membranes rupture, subjecting it to compression between the fetus and pelvis |
| Ultrasound | Transvaginal or transabdominal visualization using high-frequency sound waves; confirm pregnancy/multifetal gestations, verify location, viability, identify structural abnormalities, guide needle placement, determine gestational age |
| Doppler ultrasound | Use of sound waves to determine Doppler shifts and directional flow; determines adequacy of flow through the placenta and umbilical cord |
| Alpha-Fetoprotein (AFP) | AFP, a predominant protein in fetal plasma, is tested in fluid aspirated from amniotic sac; indication of open neural tube defects (if elevated), trisomy 21 (down syndrome) (if low), gestational trophoblastic disease (low) (hydatifiform....) |
| Chorionic Villus Sampling | Chronic villi are aspirated; 10-12 wk gestation; diagnosis of chromosomal, metabolic, or DNA abnormalities |
| Amniocentesis | Aspiration of amniotic fluid; best at 15-20 wk; evaluation of cast-off fetal cells for chromosomal abnormalities, intrauterine infections, AFP, fetal lung maturity, hemolytic diseases when Rh incompatibility is suspected |
| Non-stress test (NST) | Electrodes and a tocotransducer detect FHR and uterine activity while the mom is at rest; after 32 wk; evaluation of FHR in response to fetal movement |
| Vibroacoustic Stimulation Test | Fetus stimulated with sound; expected response is HR acceleration; confirms non-reactive NST and shorten times required to obtain high-quality NST data |
| Contraction Stress Test | Evaluation of FHR using electrodes and tocotransducer in response to mild uterine contractions; evaluation of FHR in response to fetal movement; may be done if NST are abnormal or questionable |
| Biophysical profile | 5 fetal assessments: FHR(from NST), breathing, gross movement, muscle tone, and volume of amniotic fluid; determine how fetal CNS reacts to acidosis and hypoxemia |
| Percutaneous umbilical blood sampling | Aspiration of fetal blood from the umbilical cord for prenatal diagnosis or therapy; management of Rh disease, diagnosis of abnormal blood clotting factors, acid-base status of the fetus, treat blood diseases, deliver therapeutic drugs to fetus |
| Maternal Assessment of Fetal Movement (kick count) | Daily evaluation of number of kicks in a prescribed amount of time; fetal movement is indicative of fetal condition and general health |
| Which part of the mature sperm contains the male chromosomes? | The head of the sperm |
| One of the assessments performed in the birth room is checking the umbilical cord for blood vessels. What finding is considered to be WNL? | Two arteries and one vein |
| What is the purpose of the ovum's zona pellucida? | Prevents multiple sperm from fertilizing the ovum |
| What is the morula? | A solid ball composed of the first cells formed after fertilization |
| The upper uterus is the best place for the fertilized ovum to implant because the: | Developing baby is best nourished The uterine fundus is richly supplied with blood and has the thickest endometrium, both of which promote optimum nourishment of the fetus |
| Some of the embryo's intestines remain within the umbilical cord during the embryonic period because the: | Abdomen is too small to contain all the organs while they are developing The abd contents grow more rapidly than the abd cavity, so part of their development takes place in the umbilical cord and only remain until about week 10 |
| A client who is 16 weeks pregnant with her first baby asks how long it will be before she feels the baby move. What is the nurse's best answer? | Within the next month you should start to feel fluttering sensations Movement is felt toward 17-20 weeks |
| What best describes what occurs during the fetal period of development? | Maturation of organ systems |
| An expectant parent says to the nurse, "When my sister's baby was born, it was covered in a cheeselike coating. What is the purpose of it?" The correct response by the nurse is to explain that the purpose of vernix caseosa is to: | Protect the fetal skin from amniotic fluid Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the skin without the protection of the vernix caseosa |
| An expectant client, diagnosed with oligohydramnios, asks the nurse about what this condition means for the baby. What should the nurse tell the client? | Oligohydramnios can cause poor fetal lung development |
| The nurse is conducting a staff in-service on multifetal pregnancy. What statement about dizygotic twin development should the nurse include in the teaching session? | Dizygotic twins arise from two fertilized ova and may be the same sex or different sexes |
| What medication would the nurse anticipate administering to the labor client who is delivering a premature infant? | Betamethasone Given to promote surfactant production in the fetus to maximize lung function |
| An infant is diagnosed with fetal anemia. What information would support that clinical diagnosis? | Passive immunity Provides temporary protection to the baby based on the transfer of maternal antibodies |
| The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score of 9, the nurse notes two vessels in its umbilical cord. What is the nurse's next action? | Assess for other abnormalities of the infant The normal finding in the umbilical cord is two arteries and one vein. Two vessels may indicate other fetal anomalies |
| A pregnant client asks the nurse how her baby gets oxygen to breathe. What is the nurse's best response? | Oxygen rich blood is delivered through the umbilical vein to the baby |
| What physical characteristics decrease as the fetus nears term? | Vernix caseosa and lanuga Brown fat in the fetus will be maintained to maintain core temperature |
| Along with gas exchange and nutrient transfer, the placenta produces many hormones necessary for normal pregnancy, including what? | Estrogen, progesterone, and human chorionic gonadotropin (hCG) |
| What characteristics of prenatal development should the nurse include for a fetus of 24 weeks, based on fertilization age? | Skin wrinkles and red, testes descending toward the inguinal rings, and fetal movement becoming progressively more noticeable |
| The nurse is explaining fetal circulation to a group of nursing students. What should be included in the teaching session? | The foramen ovale shunts blood from the right atrium to the left atrium, and the ductus venosus shunts blood from the liver to the inferior vena cava |
| What purposed are performed by the amniotic fluid? | Cushions the fetus, allows for buoyancy for fetal movement, maintains a stable temperature for the fetus |
| Intervillous spaces | Site of exchange of substances between the mother and fetus |
| Umbilical veins | Carries oxygenated blood and nutrients to the fetus |
| Umbilical artery | Carries deoxygenated blood and waste products from the fetus |
| A pregnant client's mother is worried that her daughter is not "big enough" at 20 weeks of gestation. The nurse palpated and measures the fundal height at 20 cm, which is even with the woman's umbilicus. What should the nurse report to them? | The body of the uterus is at the belly button level, just where is should be at this time |
| While the VS of a pregnant client in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. What nursing intervention is appropriate? | Have the client turn to her left side and recheck her BP in 5 mins |
| A pregnant client has come to the ED with complaints of nasal congestion and epistaxis. What is the correct interpretation of these symptoms by the health care provider? | Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds |
| Which suggestion is appropriate for the pregnant client who is experiencing heartburn? | Use Tums or Alkamints to obtain relief, as directed by the HCP |
| While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions? | These occur throughout pregnancy, but you may not feel them until the third trimester |
| What is the reason for vascular volume increasing by 40% to 60% during pregnancy? | Provides adequate perfusion for the placenta The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta |
| Physiologic anemia often occurs during pregnancy because of? | Dilution of hemoglobin concentration |
| What are the only 3 positive signs of pregnancy? | Auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner |
| A client is currently pregnant; she has a 5 y/o son and a 3 y/o daughter. She had one other pregnancy that terminated at 8 weeks. What are her gravida and para? | Gravida 4, para 2 |
| A client's last menstrual period was June 10. What is her estimated date of delivery? | March 17 (Minus 3 months, plus 7 days) |
| Why should a woman in her first trimester of pregnancy expect to visit her HCP every 4 weeks? | The conditions of the expectant mother and fetus can be monitored |
| A client in her first trimester complains of N/V. She asks, "Why does this happen?" What is the nurse's best response? | "It may be due to changes in hormones" Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. |
| What advice to the client is one of the most effective methods for preventing venous stasis? | Rest often with the feet elevated Improves venous return and prevents venous stasis |
| A client notices that the HCP writes "positive Chadwick's sign" on her chart. She asks the nurse what this means. What is the nurse's best response? | It refers to the bluish color of the cervix in pregnancy |
| To relieve a leg cramp, what should the client be instructed to perform? | Dorsiflex the foot |
| A client, gravida 2 para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is palpated 3 cm below the umbilicus. This finding is? | Lower than normal for gestational age By 20 wk, the fundus should reach the umbilicus |
| What complaint made by a client at 35 weeks of gestation requires additional assessment? -Abd pain -Ankle edema in pm -Backache w/prolonged standing -SOB climbing stairs | Abd pain May indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae |
| A gravida client at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include? | Observation of posture and body dynamics Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis |
| A client in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse give about safe travel during pregnancy? | If you are traveling by car, stop to walk every 1-2 hours Car travel is safe during normal pregnancies, suggest that she stop to walk every 1-2 hours so she can empty her bladder, also helps decrease the r/f thrombosis that is elevated during pregnancies |
| The client has just learned she is pregnant and overhears the gynecologist saying she has a positive Chadwick's sign. When the client asks the nurse what this means, how should the nurse respond? | This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix |
| When a pregnant woman develops ptyalism (excessive salivation), what should the nurse advise? | Chew gum or suck on lozenges between meals Small, frequent meals and use of chewing gum and oral lozenges offer limited relief for some women |
| A pregnant immigrant has an unknown immunization history. When she presents for routine vaccinations, what will the nurse administer? | Hepatitis B In general, immunizations with live virus vaccines (measles, mumps, rubella, smallpox) are contraindicated during pregnancy. Inactivated vaccines are safe (tetanus, hep B, influenza) |
| When the pregnant woman develops changes caused by pregnancy, the nurse recognizes that the darkly pigmented vertical midabdominal line is the: | Linea nigra A dark, pigmented line from the fundus to the symphysis pubis. |
| When documenting a client encounter, what term will the nurse use to describe the woman who is in the 28th week of her first pregnancy? | Primigravida |
| You are performing assessments for an obstetric client who is 5 months pregnant with her third child. Which finding would cause you to suspect the client was at risk? | Fundal height is below the umbilicus |
| What is the best explanation that you can provide to a pregnant client who is concerned that she has pseudoanemia of pregnancy? | Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition |
| What physiologic finding is consistent with normal pregnancy? | Cardiac output increases during pregnancy As a result of increased stroke volume and heart rate |
| A pregnant client complains that since she has been pregnant, her nose is always stuffed and she feels like she has a cold. Past medical history is negative for respiratory problems. What is the most likely cause for the client's presentation? | Effects of estrogen on the respiratory tract Increasing estrogen levels during pregnancy can affect the respiratory tract passages, leading to increased vascular responses that manifest as coldlike symptoms |
| A pregnant client complains of frequent heartburn that she has never experience before and wonders why it's occurring now. The best response the nurse can provide is? | Explain to the client that physiologic changes caused by pregnancy make her more likely to experience these types of symptoms It is a normal abnormal finding |
| What physiologic event may lead to increased constipation during pregnancy? | Decreased motility in the intestines |
| Which physiologic findings are seen with respect to gallbladder function that might lead to development of gallstones during pregnancy? | Prolonged emptying times |
| What finding would indicate a potential complication related to renal function during pregnancy? | Increase in serum creatinine level Serum creatinine and BUN levels are expected to decrease with pregnancy |
| A pregnant client notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products. What would the priority nursing intervention be? | Let the client know this is a common finding that occurs during pregnancy Known as chloasma or melisma (mask of pregnancy) and is a result of pigmentation changes relative to hormones |
| Use Nagele's rule to determine the EDD for a client whose last menstrual period started on April 12. | January 19 |
| What client health behavior in the first trimester would the nurse identify as a risk factor in pregnancy? | Relaxing in a hot tub for 30 mins/day several days a week Pregnant women should avoid activities that might cause hyperthermia |
| A client who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition? | Death before or after birth Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight, preterm birth, and SIDS It does not cause congenital abnormalities, hypoglycemia, or withdrawal syndrome |
| The client with an IUD has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action? | The IUD will need to be removed to avoid complications such as miscarriage or infection A therapeutic abortion is not indicated unless infection occurs |
| The HCP reports that the primigravida's fundus can be palpated at the umbilicus. Which priority question will the nurse include in the client's assessment? | Have you felt a fluttering sensation in your lower pelvic area yet? Quickening is the 1st maternal sensation of fetal movement and is detected at approx. 20 wk in the primigravida and 16 wk in the multigravida |
| A patient at 24 wk gestation reports to the clinic nurse that she is tired all the time. What is the nurse's best response? | I'll make sure you HCP is informed of your concern She is experiencing classic signs of physiologic anemia |
| A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all the time. The patient's urine test is positive for hCG. What is the best nursing action related to this information? | Determine if there are any factors that might prohibit her from seeking medical care The pt has presumptive and probable indications of pregnancy, however, she has not sought out health care until late in the first or early in the 2nd trimester |
| The nurse is scheduling the next apt for a healthy primigravida currently at 28 weeks gestation. When will the nurse schedule the next prenatal visit? | 2 weeks From 29-36 weeks, routine prenatal assessment is every 2 weeks. If the pregnancy is high risk, the patient will see the HCP more frequently |
| The nurse is assessing a pt during a routine prenatal visit, her pregnancy has been unremarkable and at her last visit her fundal height measurement was 23 cm. The nurse measures the pt's fundal height at 24 cm. What is the next nursing action? | Ask the pt when she last felt fetal movement The fundal height is 3 cm less than it should be, so the nurse is concerned about fetal well-being. Fetal movement is one of the first indicators of fetal well-being |
| A pregnant client reports she works in a long term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine. As a nurse, you know some immunizations are safe to administer during pregnancy, such as? | Tetanus, influenza, hep A and B |
| The nurse is teaching a pregnant client about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? | Watery vaginal discharge (ruptured membranes), puffiness of the face or around the eyes and visual disturbances (preeclampsia or eclampsia) |
| The nurse is planning care for a client in her first trimester of pregnancy who is experiencing N/V. Which interventions should the nurse plan to teach this patient? | Suck on hard candy, drink fluids frequently but separate from meals, eat crackers or dry cereal before arising in the morning |
| What are presumptive signs of pregnancy? | Quickening, amenorrhea, and Chadwick's sign |
| What factors contribute to the presence of edema in the pregnant client? | Diet consisting of processed foods (they're high in sodium content), last trimester of pregnancy (as pregnancy progresses, bc of the weight of the uterus, compression takes place, leading to edema formation), and decreased venous return |
| The capacity of the uterus in a term pregnancy is how many times its prepregnant capacity? | 500 The prepregnant capacity of the uterus is about 10 mL, and it reaches 5000 mL by the end of the pregnancy, which reflects a 500 fold increase |
| The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that he's doing now, he could tell her when the contractions are? | At their acme (most intense) When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful |
| The nurse is explaining to nursing students what occurs during active labor as the uterus contracts. What statement explains the maternal-fetal exchange of oxygen and waste products during a contraction? | Diminishes as the spiral arteries are compressed During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle |
| The nurse is directing an unlicensed assistive personnel (UAP) to take maternal VS between contractions. Which statement is the best rationale for assessing maternal VS between contractions? | Maternal circulating blood volume increases temporarily during contractions During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases BP |
| Uncontrolled maternal hyperventilation during labor results in? | Respiratory alkalosis Rapid deep respirations cause the laboring woman to lose CO2 through exhalation, resulting in respiratory alkalosis |
| Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? | Engagement Occurs when the presenting part fully enters the pelvic inlet |
| Which mechanism of labor occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under symphysis? | Extension |
| Which mechanism of labor occurs when the fetus enters the pelvic inlet? | Internal rotation This rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis |
| Which mechanism of labor occurs after the birth of the head? | External rotarion The head turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anterioposterior diameter of the pelvic outlet |
| The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by? | Pulling the cervix over the fetus and amniotic sac |
| Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have? | Increased blood volume |
| The nurse is assessing the duration of a client's labor contractions. Which action does the nurse implement to assess the duration of labor contractions? | Assess from the beginning to the end of each contraction Duration of labor contractions is the average length of contractions from beginning to end |
| What event is the best indicator of true labor? | Cervical dilation and effacement The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix |
| Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? | Flexion |
| An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates? | Lightening As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps |
| A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on average, for a nullipara will last how long? | 8-10 hours The second phase of labor lasts 50 minutes and the transition phase lasts 3 1/2 hours for a nullipara A multipara's active phase of labor is 6-7 hours |
| A client just delivered a baby by the vaginal route. The client asks the nurse why the baby's head is not round, but oval. Which explanation should the nurse give to the client? | This results from molding |
| A client whose cervix is dilated to 5 cm is considered to be in which phase of labor? | Active phase Characterized by a dilation of 4-7 cm |
| A client whose cervix is dilated to 2 cm is considered to be in which phase of labor? | Latent phase Beginning of true labor until 3 cm |
| A client whose cervix is dilated completely is considered to be in what stage of labor? | Second stage Begins when the cervix is completely dilated until the birth of the baby |
| A client who just gave birth but has no expelled the placenta is considered to be in what stage of labor? | Third stage From the birth of the baby until expulsion of the placenta |
| The nurse is assessing a patient in the active phase of labor. What should the nurse expect during this phase? | The client is requesting pain medication Contraction intensity and discomfort increase to the point where women often request pain medication |
| What should the nurse expect during the latent phase? | Sociability and excitability |
| At what phase does the urge to push occur? | At the end of the transition phase or the second stage of labor |
| What should the nurse expect during the transition phase? | Loss of control and irritability |
| A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement? | The acme The peak or period of greatest strength during the middle of a contraction cycle |
| A client in labor presents with a breech. The nurse understands that a breech presentation is associated with? | Umbilical cord compression It can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis |
| The primary difference between the labor of a nullipara and that of a multipara is? | Total duration of labor Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter |
| Which maternal factor may inhibit fetal descent? | A full bladder May inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part |
| Which assessment finding would cause a concern for a client who had just delivered vaginally? | Client complains of fingers tingling May represent respiratory alkalosis due to hyperventilation during labor |
| Which clinical findings would be considered to be normal for a preterm fetus during the labor period? | Baseline tachycardia Because the nervous system is immature, the preterm fetus will have a baseline tachycardia bc of stimulation of the sympathetic nervous system. All others would indicate abnormal findings and fetal compromise |
| On admission to the labor and birth unit, a 38 y/o female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal exam. What is the priority intervention? | Notify the HCP It's considered an abnormal presentation so the physician should be notified and the process of a C section should be initiated |
| An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is? | Bloody mucus drainage from vagina |
| If a notation on the client's health record states that the fetal position is LSP, this means that the: | Buttocks are in the left posterior quadrant of the pelvis LSP explains the position of the fetus in the maternal pelvis L=Left side of pelvis, S= sacrum (fetus is in breech presentation), P= Posterior quadrants of the pelvis |
| The assessment finding which indicates that the client is in the active phase of the first stage of labor is? | Dilation of 4-7 cm |
| To determine if the client is in true labor, the nurse would assess for changes in? | Cervical dilation |
| The examiner indicates to the labor nurse that the fetus is in the left occiput anterior position (LOA). To facilitate the labor process, how will the nurse position the laboring patient? | On her left side By the use of gravity, the fetus will most likely stay in the LOA position, and increases perfusion of the placenta and increases oxygen to the fetus |
| The primipara at 39 weeks gestation states to the nurse "I can breathe easier now." What is the nurse's best response? | That process is called lightening. Do you have to urinate more frequently? |
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