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The pregnant client has an abnormal 1-hour glucose screen and completes a 3-hour, 100-g oral glucose tolerance test (OGTT). Which test results should the nurse interpret as being abnormal?
- A. Fasting blood glucose = 104 mg/dL
- B. 1-hour = 179 mg/dL
- C. 2-hour = 146 mg/dL
- D. 3-hour = 129 mg/dL
Correct Answer: A
Rationale: The fasting blood glucose of 104 mg/dL is abnormal for the OGTT; normal is 95 mg/dL or lower. A 1-hour OGTT value of 179 mg/dL is normal; normal is 180 mg/dL or lower. The 2-hour OGTT value of 146 mg/dL is normal; an abnormal value is 155 mg/dL or higher. The 3-hour OGTT value of 129 mg/dL is normal; an abnormal value is 140 mg/dL or higher.
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The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6°F (38.7°C), and the FHR is 120 with minimal variability and no accelerations. The client’s group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement? Select all that apply.
- A. Prepare for cesarean birth due to chorioamnionitis
- B. Start oxytocin for labor induction
- C. Start antibiotics as directed for the GBS infection
- D. Prepare the client for epidural anesthesia
- E. Notify the neonatologist of the client’s status
- F. Administer a cervical ripening agent
Correct Answer: A,C,D,E
Rationale: Because this client is not in labor and chorioamnionitis is possible, a cesarean birth is indicated. The client should be given antibiotics as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery. Starting oxytocin (Pitocin) would prolong the time to delivery. Administering a cervical ripening agent would prolong the time to delivery.
The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
- A. Continue to monitor the client’s bleeding and weigh the peripads.
- B. Call the client’s HCP and request an additional visual examination.
- C. Prepare to give oxytocin to stimulate uterine muscle contraction.
- D. Document the findings as normal with no interventions needed at that time.
Correct Answer: B
Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.
The client has a vaginal delivery of a full-term newborn. Immediately after delivery, the nurse assesses that the client’s perineum and labia are edematous, but she does not have an episiotomy or a perineal laceration. Which intervention should the nurse implement?
- A. Give her an ice pack to apply to the perineum.
- B. Teach her to relax her buttocks before sitting.
- C. Apply warm packs to the affected areas.
- D. Provide a plastic donut cushion for sitting.
Correct Answer: A
Rationale: If perineal edema is present, ice packs should be applied for the first 24 hours. Ice reduces edema and vulvar irritation. The client should be taught to tighten, not relax, her buttocks when sitting. This compresses the buttocks and reduces pressure on the perineum. After 24 hours, heat is recommended to increase circulation to the area. Donut cushions should be avoided because they promote separation of the buttocks and decrease venous blood flow to the area, thus increasing pain.
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.
- A. Place the side of one hand just above the client’s symphysis pubis.
- B. Press deeply into the abdomen.
- C. Place the other hand at the level of the umbilicus.
- D. Massage the abdomen in a circular motion.
- E. Position the client in the supine position.
- F. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.
Correct Answer: E,A,C,B,D,F
Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.