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The nurse is reviewing the laboratory report from the first prenatal visit of the pregnant client. Which laboratory result should the nurse most definitely discuss with the HCP?
- A. Hemoglobin 11 g/dL; hematocrit 33%
- B. White blood cell (WBC) count: 7000/mm3
- C. Pap smear: human papilloma virus changes
- D. Urine pH: 7.4; specific gravity 1.015
Correct Answer: C
Rationale: A Pap smear with HPV changes reflects an abnormal result. HPV changes are a risk factor for cervical cancer. The nurse should discuss the result with the HCP because it requires further assessment and follow-up. A normal Hgb is 12—15 g/dL; nutritional counseling should be initiated when the Hgb is less than 12 g/dL. An Hct of 33% is also low (normal Hct value = 38% to 47%; this decreases by 4% to 7% in pregnancy), but increasing the Hgb with iron-rich foods should also raise the Hct. A WBC count of 7000/mm3 is within the normal range of 5000 to 12,000/mm3. A urine pH of 7.4 is within the normal range of 4.6 to 8.0; the specific gravity is within the normal range of 1.010 to 1.025.
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The client admitted in preterm labor is told that an amniocentesis needs to be performed. The client asks the nurse why this is necessary when the HCP has been performing ultrasounds throughout the pregnancy. Which is an appropriate response by the nurse?
- A. “Your baby is older now, and an amniocentesis provides us with more information on how your baby is doing.”
- B. “An amniocentesis could not be Performed before 32 weeks, so you will be having this test from now until delivery.”
- C. “Your doctor wants to make sure that there are no problems with the baby that an ultrasound might not be able to identify.”
- D. “With your preterm labor your doctor needs to know your baby’s lung maturity; this is best identified by amniocentesis.”
Correct Answer: D
Rationale: The amniocentesis is being performed to determine fetal lung maturity. Once fetal lung maturity is determined, appropriate care can be planned, including administration of betamethasone, administration of tocolytics, or delivery of the baby. While an amniocentesis can provide fetal information that an ultrasound cannot, the rationale for the amniocentesis is to determine lung maturity. Stating additional information is too broad. An amniocentesis can be performed as early as 12 weeks’ gestation, not after 32 weeks. The amniocentesis is not being performed to identify fetal anomalies.
The nurse assesses the fundal height for multiple pregnant clients. For which client should the nurse conclude that a fundal height measurement is most accurate?
- A. The pregnant client with uterine fibroids
- B. The pregnant client who is obese
- C. The pregnant client with polyhydramnios
- D. The pregnant client experiencing fetal movement
Correct Answer: D
Rationale: Excessive fetal movement may make it difficult to measure the client’s fundal height; however, it should not cause an inaccuracy in the measurement. Fibroids can increase fundal height and give a false measurement. Obesity can increase fundal height and give a false measurement. Polyhydramnios can increase fundal height and give a false measurement.
The nurse advises the client with constipation to increase intake of which food?
- A. High-fiber fruits and vegetables
- B. White rice
- C. Processed meats
- D. Sugary desserts
Correct Answer: A
Rationale: High-fiber fruits and vegetables promote bowel regularity, relieving constipation safely during pregnancy.
The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?
- A. Transition
- B. Active
- C. Active pushing
- D. Latent
Correct Answer: D
Rationale: During the latent phase (1—3 cm), the client is usually happy and talkative. During the transition phase (8—10 cm), the client is usually more restless, irritable, and more likely to lose control. During the active phase (4—7 cm), the client may become more anxious and fatigued and needs to concentrate on breathing techniques to cope with the increasingly stronger contractions. The client who is actively pushing is focusing on how effective she is in the descent of the fetus and concentrating on how she is coping with contractions. She is usually not expressing happiness or laughter, and is not talkative.
The nurse’s assessment findings of the pregnant client include darkening of areola and nipple, presence of Goodell’s sign, leukorrhea, HR 124 bpm, dysuria, and heartburn. Of these findings, how many require further evaluation?
- A. 3
Correct Answer: 3
Rationale: There are three abnormal findings that require further evaluation. Leukorrhea needs to be distinguished from a vaginal infection, such as Candida albicans or a sexually transmitted infection. Heart rate can increase by 10 to 15 bpm during pregnancy, but an increase to 124 bpm is too high. Dysuria may be a sign of a UTI. Darkening of the areola and nipple, Goodell’s sign, and heartburn are normal findings during pregnancy and do not require further evaluation.