Nokea
The 38-year-old pregnant client at 22 weeks’ gestation has just been told she has hydramnios after undergoing a sonogram for size greater than dates. The nurse should further assess for which conditions associated with hydramnios? Select all that apply.
- A. A congenital anomaly
- B. Gestational diabetes
- C. Chronic hypertension
- D. TORCH infections
- E. Preeclampsia
Correct Answer: A,B,D
Rationale: In cases of anencephaly, the fetus is thought to urinate excessively because of overstimulation of the cerebrospinal centers, resulting in hydramnios. The nurse should further assess for gestational diabetes. Hydramnios is thought to occur from excessive fetal urination due to fetal hyperglycemia. Infants with mothers infected with toxoplasmosis, rubella, CMV, or herpes simplex virus infections (TORCH) are more likely to have hydramnios due to the inflammatory response and fluid accumulation. Chronic hypertension is not associated with excess amniotic fluid. Preeclampsia is not associated with excess amniotic fluid.
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The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
- A. Prepare for delivery.
- B. Notify the obstetrician.
- C. Apply oxygen nasally.
- D. Reposition the client.
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.
Which response by the nurse about Chadwick's sign is most accurate?
- A. It's a bluish discoloration of the cervix, vagina, and vulva that occurs as a result of the presence of an increased number of blood vessels.
- B. It's a softening of the cervix that occurs because of an increased amount of blood flowing to the reproductive organs.
- C. It's a dark brown line extending from the umbilicus to the symphysis pubis that occurs as a result of hormonal changes.
- D. None of the above
Correct Answer: A
Rationale: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.
The nurse is counseling the pregnant client who has painful hemorrhoids. Which initial recommendation should be made by the nurse?
- A. Apply steroid-based creams.
- B. Modify the diet to include more fiber.
- C. Treat these surgically before delivery.
- D. Increase intake of foods with flavonoids.
Correct Answer: B
Rationale: An initial recommendation should be a high-fiber diet because high-fiber foods increase intestinal bulk and make passage of stool easier. Steroid-based creams are frequently used for hemorrhoids, although evidence does not support their effectiveness. Surgical intervention to remove hemorrhoids is not recommended in pregnancy because hemorrhoids frequently resolve after pregnancy. Flavonoids aid in symptom relief, although they are not recommended as the first line of treatment.
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
The nurse considers prenatal teaching successful when the class correctly identifies which of the following as a danger sign of pregnancy?
- A. Headache and swelling of the face and fingers
- B. Constipation and flatulence on a regular basis
- C. Lower extremity muscle cramping and varicosities
- D. Large amounts of odorless, colorless vaginal secretions
Correct Answer: A
Rationale: Headache and swelling of the face and fingers may indicate preeclampsia, a serious condition requiring immediate attention.