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The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural?
- A. White blood cells: 24,000/mm3
- B. Glucose: 78 grams/dL
- C. Hemoglobin: 10.2 g/dL
- D. Platelets: 100,000/mm3
Correct Answer: D
Rationale: The nurse should report the low platelet count of 100,000/mm3 (normal is 150,000 to 450,000/mm3). A low count can contribute to bleeding and affect the use of epidural anesthesia. The WBC count in labor is normally increased due to the stress of labor and can be as high as 25,000/mm3 to 30,000/mm3. The glucose level normally falls during labor because of an expenditure of energy in labor. Anemia or a reduction in the Hgb and Hct is common in pregnancy. Hgb levels less than 10 g/dL are considered abnormal in pregnancy.
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The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?
- A. Turn the client onto her left side.
- B. Turn the client onto her right side.
- C. Notify the attending obstetrician.
- D. Apply oxygen by nasal cannula.
Correct Answer: A
Rationale: When the laboring client lies flat on her back, the gravid uterus completely occludes the inferior vena cava and laterally displaces the subrenal aorta. This aortocaval compression reduces maternal cardiac output, producing dyspnea, diaphoresis, tachycardia, and hypotension. Other symptoms include air hunger, nausea, and weakness. A left side-lying position decreases aortocaval compression. Lying on the right side increases aortocaval compression. Notifying the obstetrician is not the first intervention. The obstetrician would be notified if symptoms are not relieved by a left side-lying position. Applying oxygen may be needed, but first the client should be placed left side-lying.
The nurse advises the client to keep the newborn's crib free of which item?
- A. Soft toys and blankets
- B. Firm mattress
- C. Fitted sheet
- D. Crib bumpers
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.
To improve sperm production, the nurse should instruct the client's husband to avoid which activities? Select all that apply.
- A. Swimming in chlorinated water
- B. Sitting in hot tubs
- C. Wearing boxer shorts
- D. Wearing colored underwear
- E. Smoking cigarettes
- F. Refraining from strenuous exercise
Correct Answer: B,E
Rationale: High temperatures from hot tubs can impair sperm production by overheating the testes. Smoking cigarettes negatively affects sperm quality and quantity.
The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
- A. Put continuous pressure on the presenting part to keep it off the cord
- B. Place the bed in Trendelenburg position
- C. Insert a urinary catheter and instill saline
- D. Continue to monitor the FHR
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.
The nurse evaluates the pregnant client with sickle cell disease during her second trimester. The nurse should identify which manifestation as being related to sickle cell disease and not the pregnancy?
- A. Hand and lower extremities edema
- B. Elevated serum blood glucose level
- C. Decreased oxygen saturation level
- D. Elevated blood pressure
Correct Answer: C
Rationale: Decreased oxygen saturation level is a clinical manifestation of sickle cell disease. Dehydration and anemia during pregnancy can result in vaso-occlusive crisis, which causes damage to RBCs and decreased oxygenation. The decrease in oxygenation manifests in decreased oxygen saturation levels. Edema is a normal finding related to pregnancy. A decrease in osmotic pressure causes a shift of body fluids into interstitial spaces, leading to edema. Elevated serum blood glucose levels after a meal help ensure that there is a sustained supply of glucose available for the fetus. Sustained elevation may be associated with pregnancy-related diabetes, not sickle cell disease. Elevated BP is associated with essential hypertension or preeclampsia.