Nokea
Which response by the nurse about Chadwick's sign is most accurate?
- A. It's a bluish discoloration of the cervix, vagina, and vulva that occurs as a result of the presence of an increased number of blood vessels.
- B. It's a softening of the cervix that occurs because of an increased amount of blood flowing to the reproductive organs.
- C. It's a dark brown line extending from the umbilicus to the symphysis pubis that occurs as a result of hormonal changes.
- D. None of the above
Correct Answer: A
Rationale: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.
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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.
Before hospitalization, an adolescent client had decided to give up her newborn for adoption. The client had an uncomplicated vaginal delivery and is still committed to her decision. Which intervention should the nurse exclude?
- A. Offer to the client a transfer to a different unit within the hospital.
- B. Talk to the client about having possible feelings of ambivalence.
- C. Initiate a case management or social work consult for the client.
- D. Notify her family to ensure that support is available upon her discharge.
Correct Answer: D
Rationale: Offering to transfer the client is appropriate and would not be excluded. The postpartum unit may be filled with sounds and sights that may distress the client. It would be appropriate for the nurse to discuss possible ambivalence with the client, as she may have increased feelings of attachment, love, and grief after delivery. Having those feelings does not necessarily mean that the client has made the wrong decision. Initiating a case management or social work consult is appropriate and would not be excluded. The client may not have support systems available because she may not have disclosed her pregnancy to others. The adolescent may not have disclosed the pregnancy to family. Although it would be appropriate for the nurse to explore the client’s support system with the client, the nurse should not contact the client’s family.
The client on the labor unit has been experiencing frequent, painful contractions for the last 6 hours. The contractions are of poor quality, and there has been no cervical change. Which interventions should the nurse implement? Select all that apply.
- A. Maintain bed rest
- B. Administer a sedative
- C. Administer an analgesic
- D. Prepare for cesarean delivery
- E. Prepare to start oxytocin
Correct Answer: A,B,C,E
Rationale: This client is experiencing a hypertonic labor pattern in which her contractions are frequent and painful, but no cervical change has occurred. This client should be encouraged to rest often. A sedative should be given to assist the client to rest. Because the contractions are painful, an analgesic should be administered to help the client relax and cope more effectively. If the hypertonic labor pattern continues, augmentation should be initiated with either an oxytocin infusion or amniotomy. A cesarean birth is not a treatment for a hypertonic labor pattern unless a nonreassuring FHR pattern is present.
The nurse assesses the 34-week pregnant client (G2P1). Place the assessment findings in the sequence that they should be addressed by the nurse from the most significant to the least significant.
- A. Pedal edema at +3
- B. BP 144/94 mm Hg
- C. Positive group beta streptococcus vaginal culture
- D. Fundal height increase of 4.5 cm in 1 week
Correct Answer: B,D,A,C
Rationale: BP 144/94 mm Hg warrants immediate evaluation. It could indicate preeclampsia, a condition that can progress to serious complications. Fundal height increase of 4.5 cm in 1 week is abnormal and requires further follow-up. Normal fundal height increase is 1 to 2 cm per week. An increase in fundal size can be related to gestational diabetes, large-for-gestational-age fetus, fetal anomalies, or polyhydramnios. Pedal edema at +3 may be a normal physiological process if it is an isolated finding. Pedal edema warrants further assessment because it can be a symptom of preeclampsia. Positive group beta streptococcus vaginal culture warrants antibiotic treatment in labor but does not warrant intervention during the pregnancy.
The pregnant client tells the nurse that she smokes two packs per day (PPD) of cigarettes, has smoked in other pregnancies, and has never had any problems. What is the nurse’s best response?
- A. “I’m glad that your other pregnancies went well. Smoking can cause both maternal and fetal problems, and it is best if you could quit smoking.”
- B. “You need to stop smoking for the baby’s sake. You could have a spontaneous abortion with this pregnancy if you continue to smoke.”
- C. “Smoking can lead to having a large baby, which can make delivery difficult. You may even need a cesarean section.”
- D. “Smoking less would eliminate the risk for your baby, and you would feel healthier during your pregnancy.”
Correct Answer: A
Rationale: The nurse is acknowledging that the client did not experience problems with her other pregnancies but is also informing the client that smoking can cause maternal and fetal problems during pregnancy. Telling the client to stop smoking for the baby’s sake is confrontational, making the client less likely to listen to the nurse’s teaching. Although spontaneous abortion is associated with tobacco use during pregnancy, the nurse is using a scare tactic rather than therapeutic communication. Smoking can lead to a fetus that is small for gestational age, not a large baby. Decreasing her smoking intake should be suggested; however, it does not eliminate the risk to the baby completely.