Nokea
The nurse explains that, in addition to increased blood volume, which other condition causes varicose veins during pregnancy?
- A. Impaired venous return
- B. Decreased cardiac output
- C. Altered center of gravity
- D. Impaired kidney function
Correct Answer: A
Rationale: Impaired venous return, due to the uterus compressing veins, causes varicose veins, compounded by increased blood volume.
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The nurse is caring for the client in preterm labor who has gestational diabetes. The nurse determines that the client has a reactive NST when which findings are noted?
- A. Two fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) above baseline for at least 15 seconds in a 20-minute period
- B. An FHR acceleration of 15 bpm above baseline for at least 10 seconds in the 40-minute time period for the NST
- C. Two FHR accelerations of 20 bpm above baseline when the mother changes position during the 20-minute NST
- D. The occurrence of at least three mild repetitive variable decelerations in the 20-minute time period for the NST
Correct Answer: A
Rationale: The FHR is monitored by the placement of an electronic fetal monitor that has an ultrasound transducer to record the FHR and a tocodynamometer to detect uterine or fetal movement. The client is given a handheld marker to indicate when she feels fetal movement. Fetal movement is accompanied by an increase in the FHR in the healthy fetus. The criterion for a reactive (normal) NST is the presence of two FHR accelerations of 15 bpm above baseline lasting 15 seconds or longer in a 20-minute period. One FHR acceleration during a 40-minute period is insufficient and indicates a nonreactive (abnormal) NST. Maternal movement can cause an inconsistency in the FHR on the monitor strip and should be avoided during an NST. The occurrence of at least three mild repetitive variable decelerations in a 20-minute period describes a nonreactive (abnormal) NST and fetal intolerance.
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
- A. An increase in maternal heart rate
- B. A decrease in the cardiac output
- C. An increase in the white blood cell (WBC) count
- D. A decreased intravascular volume during contractions
Correct Answer: A
Rationale: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.
Two hours after the client’s vaginal delivery, she reports feeling “several large, warm gushes of fluid” from her vagina. The nurse assesses the client’s perineum and finds a large pool of blood on the client’s bed. Which nursing action is priority?
- A. Encourage the client to ambulate to the bathroom in order to empty her bladder.
- B. Place two hands on the uterine fundus and prepare to vigorously massage the uterus.
- C. Reassure the client that heavy bleeding is expected in the first few hours postpartum.
- D. Support the lower uterine segment with one hand and assess the fundus with the other.
Correct Answer: D
Rationale: A full bladder may displace the uterus, causing increased bleeding. However, a more complete assessment must be performed prior to getting the client out of bed to prevent increased bleeding and syncope. Vigorously massaging the uterus may result in inversion of the uterus. The client should not simply be reassured that heavy bleeding is expected because further assessment is necessary before concluding that the client’s blood loss is WNL. The nurse’s first action should be to support the lower uterine segment and to assess the fundus. Increased bleeding will occur if soft or “boggy.” Failing to support the lower uterine segment may result in inversion of the uterus.
If the client reports the following signs and symptoms, which one represents a probable sign of pregnancy?
- A. Absence of monthly periods
- B. Abdominal enlargement
- C. Nausea and vomiting
- D. Frequent urination
Correct Answer: B
Rationale: Abdominal enlargement is a probable sign of pregnancy, as it is more objective and indicative of uterine growth.
During the first postpartum checkup, the nurse is assessing whether the client’s chloasma has diminished. At which anatomical location is the nurse performing the assessment?
- A. Perineum
- B. Abdomen
- C. Breasts
- D. Face
Correct Answer: D
Rationale: Chloasma does not appear on the perineum. Chloasma does not appear on the abdomen. Chloasma does not appear on the breasts. The nurse should be assessing the skin over the cheeks, nose, and forehead for chloasma.