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The client at 32 weeks’ gestation presents to a hospital with a severe headache. Her admission BP is 184/104 mm Hg. Based on the assessment and findings of the serum laboratory report, which most severe complication warrants the nurse’s further assessment?
- A. Renal failure
- B. Liver failure
- C. Preeclampsia
- D. HELLP syndrome
Correct Answer: D
Rationale: It is most important for the nurse to further assess for HELLP syndrome, a variation of pregnancy-induced hypertension characterized by hemolysis (elevated bilirubin), elevated liver enzymes, and low platelets. The laboratory results do not show the serum creatinine level, so no inferences can be made about renal failure. Although liver enzymes are elevated, HELLP syndrome is a more severe complication associated with pregnancy. Preeclampsia commonly coexists with HELLP syndrome; however, these laboratory findings show worsening symptoms that are associated with HELLP syndrome.
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The client has a vaginal delivery of a full-term newborn. Immediately after delivery, the nurse assesses that the client’s perineum and labia are edematous, but she does not have an episiotomy or a perineal laceration. Which intervention should the nurse implement?
- A. Give her an ice pack to apply to the perineum.
- B. Teach her to relax her buttocks before sitting.
- C. Apply warm packs to the affected areas.
- D. Provide a plastic donut cushion for sitting.
Correct Answer: A
Rationale: If perineal edema is present, ice packs should be applied for the first 24 hours. Ice reduces edema and vulvar irritation. The client should be taught to tighten, not relax, her buttocks when sitting. This compresses the buttocks and reduces pressure on the perineum. After 24 hours, heat is recommended to increase circulation to the area. Donut cushions should be avoided because they promote separation of the buttocks and decrease venous blood flow to the area, thus increasing pain.
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
The pregnant client presents to a clinic with ongoing nausea, vomiting, and anorexia at 29 weeks’ gestation. Her Hgb level is 5 g/dL, and a blood smear reveals that newly formed RBCs are macrocytic. Which condition should the nurse further explore?
- A. Sickle cell anemia
- B. Folic acid deficiency anemia
- C. Beta-thalassemia minor
- D. Beta-thalassemia major
Correct Answer: B
Rationale: With the client’s symptoms and laboratory findings, the nurse should further explore folic acid deficiency. It is usually seen in the third trimester and coexists with iron-deficiency anemia. Sickle cell anemia is an inherited disorder in which the Hgb is abnormally formed. The chief symptom among individuals with sickle cell anemia is pain. Beta-thalassemia minor is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule. Beta-thalassemia minor typically results in mild anemia. Beta-thalassemia major is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule, but it is more severe than beta-thalassemia minor. Pregnancy in individuals with beta-thalassemia major is rare. Symptoms are usually severe anemia that warrants transfusion therapy.
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
- A. The fetus is approximately 2 cm below maternal ischial spines.
- B. The cervix is totally dilated and effaced, with fetal engagement.
- C. The fetus is breech and posterior to the client’s pelvis.
- D. The fetal lie is transverse, and the fetal attitude is flexion.
Correct Answer: C
Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.
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.