Nokea
The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
- A. Falling beta human chorionic gonadotropin (BHCG) measurement
- B. Low progesterone measurement
- C. Ultrasound showing a lack of fetal cardiac activity
- D. Ultrasound determining crown-rump length
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.
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The nurse is assessing pregnant clients. During which time frames should the nurse expect clients to report frequent urination throughout the night? Select all that apply.
- A. Before the first missed menstrual period
- B. During the first trimester
- C. During the second trimester
- D. During the third trimester
- E. One week following delivery
Correct Answer: B,D
Rationale: Urinary frequency is most likely to occur in the first and third trimesters. First-trimester urinary frequency occurs as the uterus enlarges in the pelvis and begins to put pressure on the bladder. In the third trimester, urinary frequency returns due to the increased size of the fetus and uterus placing pressure on the bladder. Women do not typically experience urinary changes before the first missed menstrual period. During the second trimester, the uterus moves into the abdominal cavity, putting less pressure on the bladder. Nocturnal frequency occurring a week after delivery may be a sign of a UTI.
Which cultural consideration should the nurse include in prenatal education?
- A. Respect client's dietary preferences and beliefs
- B. Ignore cultural practices
- C. Standardize all education materials
- D. Avoid discussing family roles
Correct Answer: A
Rationale: Respecting the client's dietary preferences and cultural beliefs ensures culturally sensitive and effective prenatal education.
The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?
- A. Male health care providers should enter the room after receiving permission from her husband.
- B. The client may prefer to eat only “hot” foods and to drink only special tea and warm water.
- C. Fathers, rather than female relatives, are usually present to provide support during the labor.
- D. She will be more likely to moan, scream, or cry out in pain during each labor contraction.
Correct Answer: A
Rationale: Some Muslim women are not comfortable with male HCPs and may prefer to have their husband in the room if a male is involved in care. Eating “hot” foods and drinking special tea and warm water are preferences of Hmong women from Laos and not those of Muslim women. The Muslim client may choose to have her husband, a male relative, or a female friend or relative provide support during childbirth, rather than her father. Muslim women are more likely to be silent and stoic during labor contractions, and not cry out in pain.
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
- A. Administer oxygen via facemask
- B. Have the HCP paged if the prolonged decelerations have not resolved.
- C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.
- D. Increase the rate of the intravenous (IV) fluids
- E. Assist the client into a different position
- F. Prepare for a vaginal examination and fetal scalp stimulation
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.
Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
- A. Document the data in the client’s health care records
- B. Notify the health care provider immediately
- C. Administer a laxative that has been prescribed pm
- D. Assess the client’s abdomen and bowel sounds
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.