Nokea
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.
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The nurse is counseling the client who has SLE. The client tells the nurse that she plans to become pregnant in the next year. Which response by the nurse is correct?
- A. “It is best to plan for your pregnancy when you have been in remission for 6 months.”
- B. “Having systemic lupus erythematosus will not impact your pregnancy in any way.”
- C. “Your chances of having an infant with congenital malformations are increased with SLE.”
- D. “You will need to be scheduled for a cesarean delivery to prevent disease transmission.”
Correct Answer: A
Rationale: Planning for pregnancy with SLE when in remission for 6 months is correct. Pregnancy planned during periods of inactive or stable disease often results in giving birth to a healthy full-term baby without increased risks of pregnancy complications. Exacerbations of SLE can occur during pregnancy and impact pregnancy outcomes. There is no risk of congenital malformations associated with maternal SLE. However, the risk for spontaneous abortion, preterm labor and birth, and neonatal death is increased. SLE is not a transmissible disease, and there is no reason for a cesarean delivery.
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.
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.
The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? Select all that apply.
- A. Oral temperature of 102.2°F (39°C)
- B. Telangiectasis on the neck and chest
- C. Mild abdominal tenderness with palpation
- D. Lochial discharge that is foul smelling
- E. White blood cell count of 16,500 cells/mm3
Correct Answer: A,D
Rationale: A temperature of 100.4°F (38°C) or higher after 24 hours postpartum is associated with a puerperal infection. Telangiectasis is red, slightly raised vascular “spiders” that may appear during pregnancy over the neck, thorax, face, or arms and remain or fade during the postpartum period. It is not indicative of an infection. Slight abdominal tenderness with palpation is a normal postpartum finding. Malodorous lochia is a common sign of a puerperal infection. A WBC count of 16,500 is normal for the postpartum client; labor produces a mild pro-inflammatory state.
Which expected outcome should the nurse include based on the client's eating habits?
- A. The client will eat three balanced meals and two snacks daily while pregnant.
- B. The client will gain a total of 50 pounds during the pregnancy.
- C. The client will take two prenatal vitamins daily.
- D. The client will report eating about 2,000 calories per day.
Correct Answer: A
Rationale: Eating three balanced meals and two snacks daily addresses the client's poor eating habits and supports nutritional needs.