Nokea
The nurse is conducting a physical assessment of the pregnant client. Which physiological cervical changes associated with pregnancy should the nurse expect to find? Select all that apply.
- A. Formation of mucus plug
- B. Chadwick’s sign
- C. Presence of colostrum
- D. Goodell’s sign
- E. Cullen’s sign
Correct Answer: A,B,D
Rationale: Cervical changes associated with pregnancy include the formation of the mucus plug. Endocervical glands secrete a thick, tenacious mucus, which accumulates and thickens to form the mucus plug that seals the endocervical canal and prevents the ascent of bacteria or other substances into the uterus. This plug is expelled when cervical dilatation begins. Cervical changes associated with pregnancy include a bluish-purple discoloration of the cervix (Chadwick’s sign) from increased vascularization. Cervical changes associated with pregnancy include the softening of the cervix (Goodell’s sign) from increased vascularization and hypertrophy and engorgement of the vessels below the growing uterus. Colostrum does occur with pregnancy but is a physiological change associated with the breasts and not with a cervical change. Cullen’s sign is a bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. It can occur with a ruptured ectopic pregnancy or acute pancreatitis.
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The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
- A. Umbilical cord prolapse
- B. Transverse fetal lie
- C. Cervical dilation not progressing
- D. Premature rupture of membranes
- E. Previous cesarean incision
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.
The nurse correctly assists the client into which position?
- A. Lithotomy
- B. Prone
- C. Sims'
- D. Trendelenburg's
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategies might the nurse suggest that the client use with her child? Select all that apply.
- A. Read books about bringing home a new baby.
- B. Think of unique names for the new baby.
- C. Help pack a bag for bringing the new baby home.
- D. Explain how pregnancy occurred, if asked.
- E. Help the child buy presents for the new baby.
Correct Answer: A,B,C,E
Rationale: Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience. Engaging the child in activities such as buying presents for the new baby helps the child to feel a part of the experience. Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
- A. Administering hydralazine
- B. Maintaining the client on bedrest
- C. Preparing the client for a nonstress test
- D. Giving betamethasone
- E. Administering metronidazole
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.