A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would
be most effective in preventing pooling of blood in
...
A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would
be most effective in preventing pooling of blood in the lower extremities?
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the
pelvic veins and increase venous return.
2. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
3. When do the anterior and posterior fontanels close?
anterior fontanel closes at 12 to 18 months and the posterior by the end of the
second month.
4. When assessing a client who is at 12-weeks gestation, the nurse recommends that
she and her husband consider attending childbirth preparation classes. When is the
best time for the couple to attend these classes?
30 weeks gestation
at 30 weeks gestation is closest (of the options) to the time parents would be ready
for such classes. Learning is facilitated by an interested pupil! The couple is most
interested in childbirth toward the end of the pregnancy when they are
psychologically ready for the termination of the pregnancy, and the birth of their child
is an immediate concern.
5. The nurse should encourage the laboring client to begin pushing when...
the cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated
at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix
1
can become edematous and may never completely dilate, necessitating an operative
delivery. Many primigravida’s begin active labor 100%and theneffacedproceed to
dilate.
6. The nurse instructs a laboring client to use accelerated-blow breathing. The client
begins to complain of tingling fingers and dizziness. What action should the nurse take?
Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
facilitated by breathing into a paper bag or cupped hands.
7. Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized edema on the right side of his head. The nurse knows that, in the
newborn, an accumulation of blood between the periosteum and skull which does
not cross the suture line is a newborn variation known as...
a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and the skull.
8. When does the head return to its normal
shape? 7-10 days
9. What did Nurse theorist Reva Rubin describe?
The initial postpartum period as the "taking-in phase," which is characterized by
maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and
closeness to families and the newborn.
10. A couple, concerned because the woman has not been able to conceive, is referred to
a healthcare provider for a fertility workup and a hysterosalpingography is scheduled.
Which post procedure complaint indicates that the fallopian tubes are patent?
Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub
diaphragmatic collection of peritoneal dye/gas.
11. Which nursing intervention is most helpful in relieving postpartum uterine contractions
or "afterpains?"
Lying prone with a pillow on the abdomen
2
Lying prone keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
12. Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
described in during the first visit with the newborn, which may be at delivery or later.
13. A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved?
A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates
toxic effects.)
14. Urinary output must be monitored when administering magnesium sulfate and should
be at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client
is 4.8 to 9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6
mg/dl. What does it help prevent? helps prevent seizures
What indicates toxic levels? 3
Respiratory rate below 12 indicates toxic effects.
Urine output of less than 100 ml/4 hours
Absent DTRs
15. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's
blood pressure drops from 120/80 to 90/60. What action should the nurse take?
Place woman in a lateral position
The nurse should immediately turn the woman to a lateral position, place a pillow or
wedge under the right hip to deflect the uterus, increase the rate of the main line IV
infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure
remains low, especially if it further decreases, the anesthesiologist/healthcare
provider should be notified immediately.
16. A client at 28-weeks gestation calls the antepartum clinic and states that she is
experiencing a small amount of vaginal bleeding which she describes as bright red.
She further states that she is not experiencing any uterine contractions or abdominal
pain. What instruction should the nurse provide?
3
Come to the clinic today for an ultrasound
Third trimester painless bleeding is characteristic of a placenta previa. Bright red
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed
by transabdominal ultrasound.
17. An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority?
Put the newborn to breast
Putting the newborn to breast will help contract the uterus and prevent a
postpartum hemorrhage--this intervention has the highest priority.
18. A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client
asks the nurse, "Why must I stay in bed all the time?" Which response is best for the
nurse to provide this client?
Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
To help preserve cardiac reserves, the woman may need to restrict her activities
and complete bedrest is often prescribed.
19. The nurse is teaching care of the newborn to a group of prospective parents and
describes the need for administering antibiotic ointment into the eyes of the newborn.
Which infectious organism will this treatment prevent from harming the infant?
Gonorrhea
Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours
after birth to prevent ophthalmic neonatorum, an infection caused by gonorrhea, and
inclusion conjunctivitis, an infection caused by chlamydia. The infant may be exposed
to these bacteria when passing through the birth canal.
20. The nurse is teaching a woman how to use her basal body temperature (BBT)
pattern as a tool to assist her in conceiving a child. Which temperature pattern
indicates the occurrence of ovulation, and therefore, the best time for intercourse to
ensure conception?
Between the time the temperature falls and rises.
In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24
to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces
progesterone. Therefore, intercourse between the time of the temperature fall and
rise is the best time for conception. The human ovum can be fertilized 16 to 24 hours
after ovulatio
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