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The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
- A. Conclude that there is a problem with the baby and call for help.
- B. Check that there is adequate gel under the transducer and reposition.
- C. Give the client oxygen via facemask at 8 to 10 liters per minute.
- D. Auscultate fetal heart rate by fetoscope and assess maternal vital signs.
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.
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The nurse is caring for the antepartum client with a velamentous cord insertion. The client asks what symptom she would most likely experience first if one of the vessels should tear. The nurse should respond that she would most likely experience which symptom first?
- A. Vaginal bleeding
- B. Abdominal cramping
- C. Uterine contractions
- D. Placental abruption
Correct Answer: A
Rationale: In a velamentous cord insertion, vessels of the cord divide some distance from the placenta in the placental membrane. Thus, the most likely first symptom would be vaginal bleeding. Abdominal cramping is unlikely to occur; velamentous cord insertion is not related to uterine activity. Contractions are unlikely to occur; velamentous cord insertion is not related to uterine activity. An abruption, when the placenta comes off the uterine wall, results in severe abdominal pain.
The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
- A. Two finger-breadths above the symphysis pubis
- B. Halfway between the symphysis pubis and the umbilicus
- C. At the level of the umbilicus
- D. Two finger-breadths above the umbilicus
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.
The nurse identifies which factor as increasing the risk of gestational hypertension?
- A. Low body mass index
- B. Family history of hypertension
- C. First pregnancy at age 20
- D. Vegetarian diet
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.
In the process of preparing the client for discharge after cesarean section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?
- A. How to manage her incision
- B. Planning for assistance at home
- C. Infant care procedures
- D. Increased need for rest
Correct Answer: B
Rationale: Although the client needs information about incision care, the priority need is for assistance at home so that she can get the rest needed for multiple demands. Because the client has had a surgical procedure, the priority consideration is for the mother to plan for additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control, and appropriate infant care. Infant care is important, but having assistance at home after a surgical procedure is more important. The need for increased rest is important, but she would not be able to obtain adequate rest without assistance at home.
The nurse is reviewing the laboratory test results of the pregnant client. Which laboratory test findings would require further follow-up from the nurse?
- A. Hemoglobin
- B. 50-g, 1-hour glucose test
- C. Glucosuria
- D. Proteinuria
Correct Answer: A
Rationale: The normal Hgb level should be 12—16 g/dL in the pregnant client. The nurse should encourage iron-rich foods. The 50-g 1-hour glucose test should be less than 140. Values over 140 warrant a 3-hour glucose screen to determine if the client has gestational diabetes. The presence of glucose in the urine (glucosuria) is negative, which is a normal finding. Proteinuria in trace amounts is common in pregnant women, although higher protein concentrations should be evaluated.