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120 Cards in this Set

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2 weeks
Fertilization (below): the sperm and egg join in the fallopian tube to form a unique human being. Forty-six chromosomes combine, which pre-determine all of a person's physical characteristics.
3 weeks
Once in the uterus, the developing embryo, called a blastocyst, searches for a nice place to implant, where it actually burrows beneath the surface of the uterus. The yolk sac, shown on the left, produces blood cells during the early weeks of life. The unborn child is only one-sixth of an inch long, but is rapidly developing. The backbone, spinal column, and nervous system are forming. The kidneys, liver, and intestines are taking shape.
4 weeks
The embryo produces hormones which stop the mother's menstrual cycle.
5 weeks
Embryo is the size of a raisin. By day twenty-one, the embryo's tiny heart has begun beating. The neural tube enlarges into three parts, soon to become a very complex brain. The placenta begins functioning. The spine and spinal cord grows faster than the rest of the body at this stage and give the appearance of a tail. This disappears as the child continues to grow.


Embryo is the size of a raisin. By day twenty-one, the embryo's tiny heart has begun beating. The neural tube enlarges into three parts, soon to become a very complex brain. The placenta begins functioning. The spine and spinal cord grows faster than the rest of the body at this stage and give the appearance of a tail. This disappears as the child continues to grow.
Embryo is the size of a raisin. By day twenty-one, the embryo's tiny heart has begun beating. The neural tube enlarges into three parts, soon to become a very complex brain. The placenta begins functioning. The spine and spinal cord grows faster than the rest of the body at this stage and give the appearance of a tail. This disappears as the child continues to grow.

7 weeks
Facial features are visible, including a mouth and tongue. The eyes have a retina and lens. The major muscle system is developed, and the unborn child practices moving. The child has its own blood type, distinct from the mother's. These blood cells are produced by the liver now instead of the yolk sac.
8 weeks
The unborn child, called a fetus at this stage, is about half an inch long. The tiny person is protected by the amnionic sac, filled with fluid. Inside, the child swims and moves gracefully. The arms and legs have lengthened, and fingers can be seen. The toes will develop in the next few days. Brain waves can be measured.
10 weeks
The heart is almost completely developed and very much resembles that of a newborn baby. An opening the atrium of the heart and the presence of a bypass valve divert much of the blood away from the lungs, as the child's blood is oxygenated through the placenta. Twenty tiny baby teeth are forming in the gums
12 weeks
Vocal chords are complete, and the child can and does sometimes cry (silently). The brain is fully formed, and the child can feel pain. The fetus may even suck his thumb. The eyelids now cover the eyes, and will remain shut until the seventh month to protect the delicate optical nerve fibers.
14 Weeks

Muscles lengthen and become organized. The mother will soon start feeling the first flutters of the unborn child kicking and moving within.
14 Weeks

Muscles lengthen and become organized. The mother will soon start feeling the first flutters of the unborn child kicking and moving within.
15 Weeks
The fetus has an adult's taste buds and may be able to savor the mother's meals.
16 Weeks
Five and a half inches tall and only six ounces in weight, eyebrows, eyelashes and fine hair appear. The child can grasp with his hands, kick, or even somersault.
20 Weeks
The child can hear and recognize her mother's voice. Though still small and fragile, the baby is growing rapidly and could possibly survive if born at this stage. Fingernails and fingerprints appear. Sex organs are visible. Using an ultrasound device, the doctor can tell if the child is a girl or a boy. The one on the left is a baby girl.


Continue to
24 weeks
Seen here at six months, the unborn child is covered with a fine, downy hair called lanugo. Its tender skin is protected by a waxy substance called vernix. Some of this substance may still be on the child's skin at birth at which time it will be quickly absorbed. The child practices breathing by inhaling amnionic fluid into developing lungs.
30 weeks
For several months, the umbilical cord has been the baby's lifeline to the mother. Nourishment is transferred from the mother's blood, through the placenta, and into the umbilical cord to the fetus. If the mother ingests any toxic substances, such as drugs or alcohol, the baby receives these as well.
32 weeks
The fetus sleeps 90-95% of the day, and sometimes experiences REM sleep, an indication of dreaming.
38 - 40 weeks
The baby, now approximately seven and a half pounds, is ready for life outside its mother's womb. At birth the placenta will detach from the side of the uterus and the umbilical cord will cease working as the child takes his first breaths of air. The child's breathing will trigger changes in the structure of the heart and bypass arteries which will force all blood to now travel through the lungs.
Acrosomal reaction
Breakdown of the hyaluronic acid in the corona radiata by enzymes from the heads of sperm; allows one spermatozoon to penetrate the ovum zona pellucida.
Amnion
The inner of the two membranes that form the sac containing the fetus and the amniotic fluid.
Embryo
The early stage of development of the young of any organism. In humans the embryonic period is from about 2 to 8 weeks' gestation and is characterized by cellular differentiation and predominantly hyperplastic growth.
Fetus
The child in utero from about the seventh to ninth week of gestation until birth.
Lanugo
Fine, downy hair found on all body parts of the fetus, with the exception of the palms of the hands and the soles of the feet, after 20 weeks' gestation.
Morula
Developmental stage of the fertilized ovum in which there is a solid mass of cells.
Umbilical cord
The structure connecting the placenta to the umbilicus of the fetus and through which nutrients from the woman are exchanged for wastes from the fetus.
Wharton's jelly
Yellow-white gelatinous material surrounding the vessels of the umbilical cord.
Antepartum
Time between conception and the onset of labor; usually used to describe the period during which a woman is pregnant.
Intrapartum
The time from the onset of true labor until the birth of the infant and delivery of the placenta.
Multigravida
Woman who has been pregnant more than once.
Multipara
Woman who has had more than one pregnancy in which the fetus was viable.
Nagele's rule
A method of determining the estimated date of birth (EDB): after obtaining the first day of the last menstrual period, subtract 3 months and add 7 days.
Nulligravida
A woman who has never been pregnant.
Nullipara
A woman who has not delivered a viable fetus.
Nullipara
A woman who has not delivered a viable fetus.
Para
A woman who has borne offspring who reached the age of viability
Para
A woman who has borne offspring who reached the age of viability
Postpartum
After childbirth or delivery.
Postpartum
After childbirth or delivery.
Preterm or premature labor
Labor occurring between 20 and 38 weeks of pregnancy. Also called premature labor.
Preterm or premature labor
Labor occurring between 20 and 38 weeks of pregnancy. Also called premature labor.
Primigravida
A woman who is pregnant for the first time.
Primigravida
A woman who is pregnant for the first time.
Primipara
A woman who has given birth to her first child (past the point of viability),whether or not that child is living or was alive at birth.
Primipara
A woman who has given birth to her first child (past the point of viability),whether or not that child is living or was alive at birth.
1 . The nurse is preparing an antenatal client for an initial assessment. What is the first task that the nurse should perform?
Provide the client with a gown.
Instruct the client to provide a clean urine specimen.
Prepare the client for a pelvic exam.
Draw blood for routine tests.
Instructing the client to provide a clean urine specimen is the first task that the nurse should perform in preparing an antenatal client for an initial assessment. Providing the client with a gown is done after obtaining the urine specimen. Prepare the client for a pelvic exam is done after or during the physical exam. Draw blood for routine tests is the last task performed. Lab tests may be added based on assessment data from the physical exam.
The nurse in the prenatal clinic is planning care for a pregnant 15-year-old client. The nurse knows that this adolescent is at risk for which maternal complication?
Postpartum hemorrhage
Hypoglycemia
Cesarean birth
Preeclampsia
Adolescents are at increased risk for preeclampsia. Postpartum hemorrhage is a complication of multiparity. Hypoglycemia is a complication of diabetes. Cesarean birth is a high-risk factor for clients over 35 years of age.
The nurse has completed the initial assessment on four prenatal clients. Which client is at greatest risk for a spontaneous preterm birth? [Hint]
A 26-year-old client with a history of diabetes.
A 17-year-old client with a hyperthyroid disorder.
A 19-year-old client with twins.
A 40-year-old client with anemia.
Twins place a patient at risk for preterm labor because of the over-distension of the uterus relative to the weeks of gestation. Diabetes places the client at risk for preeclampsia and cesarean birth. Hyperthyroid disorders are associated with an increased risk of postpartum hemorrhage. Clients older than 35 are at risk for preeclampsia and cesarean birth.
The nurse is assessing the fundal height of a client at 12 weeks' gestation. The nurse should expect the fundus to be: [Hint]
Level with the umbilicus.
Halfway between symphysis and umbilicus.
Slightly below ensiform cartilage.
Slightly above symphysis pubis.
The fundal height is expected to be slightly above the symphysis pubis for a client at 12 weeks' gestation. At the level of the umbilicus is expected at 20-22 weeks' gestation. Halfway between the symphysis and umbilicus is expected at 16 weeks' gestation. Slightly below the ensiform cartilage is expected at 36 weeks' gestation.
A nurse is completing an assessment on a first trimester antepartal client with a hemoglobin level of 10.8 g/dL. What is the priority nursing action at this time?
Obtaining an order for iron supplementation is the priority nursing action on a first trimester antepartal client with a hemoglobin level of 10.8 g/dL. Refer the client for nutritional counseling is an important intervention at 12.0 g/dL but is not the priority at this time. Obtaining an order for type and cross match is not needed at this time. Transfusions may be given at levels below 6.0-8.0 g/dL. Evaluating the client for signs of infection is the appropriate action for an elevated white blood cell.
An antepartum client tells the nurse her last period was May 18 to 24. The nurse uses Nagele's rule to compute the client's expected date of birth. What is the correct date of birth?
February 25 (of the next year) is the correct date of birth based on the fact that the first day of her last period was May 18. Calculating with Nagele's rule (subtract three months first, then add 7 days to the first day of the last menstrual period) provides for the EDB of February 25.
An antepartal client at 29 weeks' gestation is assessed in the prenatal clinic. All assessment data are within normal limits. When should the nurse schedule the client's next appointment?
The client's next appointment, if all assessment data are within normal limits, should be scheduled in two weeks. In one week is recommended after 36 weeks' gestation. In four weeks is the recommended interval for the first 28 weeks of gestation.
A nurse assesses four clients in the prenatal clinic. Which client will present with the most accurate fundal height related to gestational age?
The client presenting with hypertension has the most accurate fundal height related to gestation. There may be difficulty accurately palpating the fundus in a client who develops hydramnios (extra amniotic fluid). The uterine size may be distorted in a client who develops uterine fibroids. There may be difficulty accurately palpating the fundus in the client with obesity.
A nurse is assessing a prenatal client at 26 weeks' gestation. The nurse anticipates measuring the fundal height at:
26 cm is the anticipated the fundal height in a prenatal client at 26 weeks' gestation (1 cm/wk between 20-36 wks). A fundal height of 20 cm correlates with a 20 wks gestation, 24 cm with 24 wks gestation, and 30 cm with 30 wks gestation.
A client who is 8 weeks' pregnant gives the following pregnancy history to the nurse: This is her fourth pregnancy; she had one abortion at 12 weeks, she had a girl born at home at 35 weeks, and she gave birth to a stillborn at 38 weeks. Which of the following is the correct documentation for this client's obstetric history?
The TPAL approach provides more detailed information about a woman's pregnancy history. Gravida 4 para 1111 is in her fourth pregnancy; she had one abortion at 12 weeks, she had a girl born at home at 35 weeks (who is still living), and she gave birth to a stillborn at 38 weeks. Gravida 3 para 0110 is a woman who has been pregnant 3 times. She had no babies born at term, had 1 preterm baby, had 1 abortion, and has no living children. She is currently pregnant. Gravida 3 para 1111 is a woman who has been pregnant 3 times. She had 1 term baby, had 1 preterm baby, had 1 abortion, and has 1 living child. Gravida 4 para 2102 is a woman who has been pregnant 4 times. She had 2 babies born at term (who are currently living) and 1 preterm baby who died. She has had no abortions. She is currently pregnant.
Diagonal conjugate
Distance from the lower posterior border of the symphysis pubis to the sacral promontory; may be obtained by manual measurement.
Obstetric conjugate
Distance from the middle of the sacral promontory to an area approximately 1 cm below the pubic crest.
Preterm or premature labor
Labor occurring between 20 and 38 weeks of pregnancy. Also called premature labor.
Gestation
Period of intrauterine development from conception through birth; pregnancy.
The nurse assesses a laboring client whose contractions occur every five to seven minutes and last for 30 seconds. Which phase of labor is this client in?
Latent phase of labor is when contractions occur every five to seven minutes and last for 30 seconds. In the active phase, contractions should occur every two to three minutes. In the transition phase, contractions should occur every one and a half to two minutes. There is no second phase.
The physician orders internal fetal monitoring for a laboring client. What criteria must the client meet prior to this procedure?
The membranes must be ruptured for internal fetal monitoring to be used for a laboring client. The fetal part must be accessible by vaginal exam but does not have to be engaged. The cervix needs to be dilated at least 2 cm. Any presentation is acceptable.
A client is admitted to the birthing center with possible rupture of membranes. What substance in the fluid could contribute to a false positive reading on Nitrazine test tape?
Lubricant in the fluid could contribute to a false positive reading on Nitrazine test tape. Feces, bacteria or meconium in the fluid will not alter the test results.
The nurse is evaluating an intrapartal client's lab results. Which laboratory finding should the nurse report to the physician or nurse-midwife?
The platelets (120,000/mm) should be reported as abnormally low, also called thrombocytopenia (normal: 250-500/000/mm). The hematocrit, leukocyte count, and white blood count are within normal limits for a laboring woman.
A nurse is receiving a report on four clients in the birthing center. Which client should the nurse anticipate giving birth first?
He client who is G5P4, 5 cm dilated, and 40% effaced would probably be the first to deliver. Multiparas usually progress faster than nulliparas. A gravida 6 with only one prior delivery would probably not progress as rapidly as the woman who is gravida 5 para 4.
A nurse is planning to perform Leopold's maneuvers on a laboring client. What should be the nurse's initial action?
Have the client void before performing Leopold's maneuvers provides for improved comfort during the evaluation for the laboring client. Positioning the client on her back is the correct position, but this is not the initial action. The examiner's hands should be warm, but this is not the initial action. Apply sterile lubricant to the abdomen is not part of the procedure.
A nurse is auscultating the heart rate of a fetus in a cephalic presentation. In which location would the nurse hear the heart rate most clearly?
The lower quadrant of the maternal abdomen is where the nurse should hear the fetal heart rate (FHR) in a cephalic presentation. Hearing the FHR at the level of the maternal umbilicus is expected of the fetus in a transverse presentation. Hearing the FHR in the upper quadrant of the maternal abdomen is appropriate for a breech presentation. FHR is heard most clearly along the back of the fetus, not at the apex of the fetal heart.
The fetal monitor has shown several late decelerations over the past 10 minutes. What does this pattern indicate?
A pattern of late decelerations indicates fetal hypoxia, caused primarily by uteroplacental insufficiency. Variable decelerations are caused by umbilical cord compression. Early decelerations are caused by head compression. Maternal fever may contribute to fetal tachycardia.
The nurse has auscultated a fetal heart rate of 80. What should be the nurse's initial action?
The nurse should check the maternal pulse because the rate of 80 could be the maternal heart rate rather than the fetal heart rate. Positioning the client on her left side, administering oxygen at 5 L per minute, and notifying the physician or nurse-midwife would be appropriate only if the rate of 80 (fetal bradycardia) has been confirmed to be the fetal heart rate.
The nurse is caring for a client at 37 weeks' gestation who has pregnancy-induced hypertension and is in the active phase of labor. How frequently should the nurse assess the fetal heart rate?
Assessing the fetal heart rate every 15 minutes is appropriate for a high-risk patient in active labor. Assessing the fetal heart rate every five minutes is appropriate for high-risk clients in the second stage of labor, every 30 minutes is appropriate in the latent phase for high-risk clients and every hour is appropriate in the latent phase for low-risk clients.
A nurse is reviewing the factors important in the process of labor. Which two pelvic types are favorable for labor and vaginal delivery?
Gynecoid and Anthropoid pelvis types are favorable for labor or delivery, whereas Android and Platypelloid pelvis types are not favorable.
A client at 39 weeks' gestation calls the clinic nurse with complaints of pelvic pressure, increased urinary frequency, and vaginal secretions. The nurse would correctly interpret these as signs and symptoms of a(n):
Pelvic pressure, increased urinary frequency, and vaginal secretions are symptoms of impending labor. Vaginal infection may be recognized by an odor to the vaginal secretions, along with back or abdominal pain and fever. Urinary tract infection will present with a strong odor to the urine, along with pain and/or burning upon urination with possible fever. Although rupture of membranes precedes labor in 12% of cases, it would likely be accompanied by the expulsion of large amounts of amniotic fluid.
A nurse is caring for a client admitted to the birthing unit with rupture of membranes for two hours. A pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged. Which possible complication should the nurse anticipate?
When a pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged, the nurse should anticipate a prolapsed cord. With placenta previa, the placenta is implanted in the lower uterine segment rather than the upper portion of the uterus and it is not a complication of ruptured membranes or cervical dilatation. Amniotic infection is a potential complication after the membranes have been ruptured for >12 hours, especially if uterine contractions are present. Abruptio placentae is the premature separation of a normally implanted placenta from the uterine wall and is not a complication of ruptured or cervical dilatation.
A G4P3 client in the transition phase of labor asks the nurse, "How much longer will it be before I have my baby?" What would be the best estimate that the nurse could provide?
One hour is a reasonable estimate of time until delivery for a multipara woman in transition. Two hours or more would be a more appropriate answer for a nullipara woman.
A laboring client complains of nausea and vomiting and increasing rectal pressure. She states, "I can't take this any more." The nurse correctly assesses that this client is in which phase of labor?
Transition is the phase of labor where clients usually complain of nausea and vomiting and increasing rectal pressure and state, "I can't take any more." A laboring client usually is able to cope in the latent and active phases of labor. Nausea, vomiting, and rectal pressure decrease during the second stage with the birth of the baby.
A nurse assesses a rise in the fundal height and a sudden gush of blood from the vagina of a postpartum client five minutes after birth. The nurse appropriately interprets these finding as:
Separation of the placenta is characterized by a rise in fundal height and sudden gush of blood five minutes after birth. Immediate postpartum hemorrhage is not characterized by a rise in fundal height. Late postpartum hemorrhage occurs 24-48 hours or more after birth. Delivery of the placenta is characterized by a decrease in fundal height.
A nurse is caring for a client during the fourth stage of labor. What are the expected assessment findings at this time?
Decreased blood pressure and increased pulse are the expected assessment findings during the fourth stage of labor.
A laboring client is lying supine with a blood pressure of 88/60. What should be the initial nursing action?
Position client on the left side will correct the supine hypotension (88/60) due to aortocaval compression. Administration of oxygen, notifying the physician or nurse-midwife, or increasing the intravenous drip rate are not initial actions because they will not correct aortocaval compression.
A pregnant client asks the nurse, "How will I know when I am close to starting labor?" The nurse correctly states that one possible sign of impending labor is:
Impending labor may be indicated by a weight loss of 2.2 to 6.6 kg (1 to 3 lb) resulting from fluid loss and electrolyte shifts produced by changes in estrogen and progesterone levels. Diarrhea, indigestion, or nausea and vomiting usually occur just prior to the onset of labor. Some women report a sudden burst of energy approximately 24 to 48 hours before labor. Abdominal discomfort can be a sign of false labor.
A laboring client complains to the nurse about intense pain located primarily in her back. Which fetal presentation should the nurse expect to see written on the client's chart?
Either occiput-posterior (LOP or ROP) position of the fetus is one that would cause a woman to complain of intense backache as the fetal head presents a larger diameter in the posterior position. The anterior positions or transverse positions do not place additional pressure on the sacrum and are not associated with intense backache.
A nurse is reviewing the factors important in the process of labor. Which two pelvic types are favorable for labor and vaginal delivery?
Gynecoid and Anthropoid pelvis types are favorable for labor or delivery, whereas Android and Platypelloid pelvis types are not favorable.
A client at 39 weeks' gestation calls the clinic nurse with complaints of pelvic pressure, increased urinary frequency, and vaginal secretions. The nurse would correctly interpret these as signs and symptoms of a(n):
Pelvic pressure, increased urinary frequency, and vaginal secretions are symptoms of impending labor. Vaginal infection may be recognized by an odor to the vaginal secretions, along with back or abdominal pain and fever. Urinary tract infection will present with a strong odor to the urine, along with pain and/or burning upon urination with possible fever. Although rupture of membranes precedes labor in 12% of cases, it would likely be accompanied by the expulsion of large amounts of amniotic fluid.
A nurse is caring for a client admitted to the birthing unit with rupture of membranes for two hours. A pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged. Which possible complication should the nurse anticipate?
When a pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged, the nurse should anticipate a prolapsed cord. With placenta previa, the placenta is implanted in the lower uterine segment rather than the upper portion of the uterus and it is not a complication of ruptured membranes or cervical dilatation. Amniotic infection is a potential complication after the membranes have been ruptured for >12 hours, especially if uterine contractions are present. Abruptio placentae is the premature separation of a normally implanted placenta from the uterine wall and is not a complication of ruptured or cervical dilatation.
A G4P3 client in the transition phase of labor asks the nurse, "How much longer will it be before I have my baby?" What would be the best estimate that the nurse could provide?
One hour is a reasonable estimate of time until delivery for a multipara woman in transition. Two hours or more would be a more appropriate answer for a nullipara woman.
A laboring client complains of nausea and vomiting and increasing rectal pressure. She states, "I can't take this any more." The nurse correctly assesses that this client is in which phase of labor?
Transition is the phase of labor where clients usually complain of nausea and vomiting and increasing rectal pressure and state, "I can't take any more." A laboring client usually is able to cope in the latent and active phases of labor. Nausea, vomiting, and rectal pressure decrease during the second stage with the birth of the baby.
A nurse assesses a rise in the fundal height and a sudden gush of blood from the vagina of a postpartum client five minutes after birth. The nurse appropriately interprets these finding as:
Separation of the placenta is characterized by a rise in fundal height and sudden gush of blood five minutes after birth. Immediate postpartum hemorrhage is not characterized by a rise in fundal height. Late postpartum hemorrhage occurs 24-48 hours or more after birth. Delivery of the placenta is characterized by a decrease in fundal height.
A nurse is caring for a client during the fourth stage of labor. What are the expected assessment findings at this time?
Decreased blood pressure and increased pulse are the expected assessment findings during the fourth stage of labor.
A laboring client is lying supine with a blood pressure of 88/60. What should be the initial nursing action?
Position client on the left side will correct the supine hypotension (88/60) due to aortocaval compression. Administration of oxygen, notifying the physician or nurse-midwife, or increasing the intravenous drip rate are not initial actions because they will not correct aortocaval compression.
A pregnant client asks the nurse, "How will I know when I am close to starting labor?" The nurse correctly states that one possible sign of impending labor is:
Impending labor may be indicated by a weight loss of 2.2 to 6.6 kg (1 to 3 lb) resulting from fluid loss and electrolyte shifts produced by changes in estrogen and progesterone levels. Diarrhea, indigestion, or nausea and vomiting usually occur just prior to the onset of labor. Some women report a sudden burst of energy approximately 24 to 48 hours before labor. Abdominal discomfort can be a sign of false labor.
A laboring client complains to the nurse about intense pain located primarily in her back. Which fetal presentation should the nurse expect to see written on the client's chart?
Either occiput-posterior (LOP or ROP) position of the fetus is one that would cause a woman to complain of intense backache as the fetal head presents a larger diameter in the posterior position. The anterior positions or transverse positions do not place additional pressure on the sacrum and are not associated with intense backache.
A G1P0 client calls the hospital and asks the nurse, "I think I am having labor pains. When should I come to the hospital?" The nurse correctly replies that the client should come in when her contractions are:
The nullipara client should come in when her contractions are five minutes apart for one hour. The multigravida client should come when contractions are three minutes apart for 30 minutes.
A G1P0 client at 39 weeks' gestation arrives at the birthing center with contractions 10-30 minutes apart. Assessment data reveals 1-2 cm cervical dilation, membranes intact, and a thick cervix. What would be the most appropriate nursing action at this time?
A client with contractions 10-30 minutes apart and 1-2 cm cervical dilation, membranes intact, and a thick cervix is in the latent phase of early labor. Send the client home to ambulate. The client will be admitted only when she begins active labor. Beginning to hydrate the client with IV fluids is not appropriate; there is no dehydration status or preterm labor. Monitoring the client with pelvic checks every hour is not appropriate until active labor and progress has been made.
A G3P0 client in active labor is admitted to the birthing center. Which data set should the nurse interpret as being within the normal range?
During the first stage of labor, normal blood pressure is 90-140/60-90, pulse 60-90, respirations 12-20/minute, and temperature <37.6°C(99.6°F).
The nurse is caring for four clients in the birthing center. The nurse should encourage which client to ambulate?
The client that is G3P2 with intact membranes and 4 cm dilation could be encouraged to ambulate. If membranes are ruptured and the presenting part is not engaged, there is risk of prolapsed cord. A multigravida at 8 or 9 cm should labor in bed or a chair.
laboring client in the birthing center has a hematocrit of 49. The nurse should anticipate that this finding is related to:
Dehydration is indicated by a hemotocrit of 49% resulting from hemoconcentration. Anemia & hemorrhage are indicated by low hemoglobin. Infection is indicated by a high white blood cell count.
A Hmong client has just given birth to a five pound baby girl. What culturally sensitive nursing action is appropriate at this time?
Offering the mother a soft-boiled egg to eat is the culturally sensitive nursing action appropriate for the postpartum Hmong client. Commenting on the daintiness of her baby girl and assisting the mother in bathing the baby is not a cultural preference. Warm foods are preferred by this culture at this time so offering cold foods would not be appropriate.
The nurse is caring for a client in the transitional stage of labor. What objective data would indicate that the client is having pain?
Dilated pupils, along with increased blood pressure, pulse and respiration rate, indicate pain. Muscles would be tense.
The nurse is caring for four laboring clients at Stage 1 of labor. Which client is demonstrating responses commonly seen during the latent phase?
A client who is happy and talkative is demonstrating responses commonly seen during the latent phase. Increased fatigue, restlessness, and anxiety are commonly seen during the active phase. Increased irritability and feeling out of control are responses commonly seen during transition. Birth occurs at the end of the second stage of labor.
A laboring client complains of numbness of nose, fingers, and toes, and spots before her eyes. What should be the initial action by the nurse?
Encourage slow shallow breaths should be the initial action by the nurse for a laboring client who complains of symptoms of hyperventilation (hypocarbia). Slow, shallow breathing will help her build up her CO2 level to balance out her excessive oxygen levels. Implementing seizure precautions, administering oxygen and notifying the physician or midwife are not appropriate nursing actions for hyperventilation.
A low-risk client's vaginal exam reveals that her cervix is dilated to 8 cm with 75% effacement. How frequently should the nurse assess this client's vital signs?
The client is in the transition phase of the first stage of labor. The nurse should assess vital signs every 30 minutes. More frequent assessment of vital signs is appropriate during the second and third stages and following anesthesia.
A G1P0 client is dilated to 4 cm on cervical exam. She tells the nurse, "I'm in pain but I'm afraid that medication might harm my baby." Which response by the nurse is the most therapeutic regarding pain medication during labor
"Pain medications do affect the baby but so do pain and stress" is the best response. Pain and stress can cause changes in the mother that can reduce the oxygen supply to the baby, whereas some medications are safe for the baby while allowing the mother to be more comfortable.
A nurse is caring for a laboring client who just received an epidural block. What fetal monitor pattern would alert the nurse to a serious problem developing?
The FHR pattern showing decreased FHR variability and late decelerations would alert the nurse to a serious problem. Increased fetal heart rate (FHR) variability and early decelerations are not an alarming pattern. Decreased FHR variability with early decelerations and variable decelerations are not related to the epidural.
A nurse is caring for a laboring client who just received an epidural block. What is the major adverse effect that the nurse should observe for?
Hypotension, due to vasodilation from the initial effects of the epidural, may be prevented with a pre-load bolus of 500cc IV solution. Unilateral block and pruritus are less common adverse effects. Hypertension may be a complication of pregnancy-induced hypertension and oxytocin inductions.
Butorphanol tartrate (Stadol) has been ordered for pain for a laboring client. What should be the nurse's initial action prior to administering the medication?
Prior to administering butorphanol tartrate (Stadol) for pain, the nurse should assess for allergies. Monitoring fetal heart rate, assessing cervical dilation and monitoring maternal vital signs are appropriate interventions, but not as the initial action.
The nurse is administering Benadryl per standing order to treat which commonly occurring side effect during epidural infusion?
Benadryl, an antihistamine, treats pruritus, a common epidural side effect. Hypotension, nausea and vomiting and general sedation are common side effects of epidural infusion, but Benadryl will not treat them.
The nurse is to administer naloxone (Narcan) intravenously. Which medication order would be the most appropriate initial dose to counteract a narcotic-induced maternal respiratory depression?
For reversal of respiratory depression in a laboring woman, the initial recommended dosage of Narcan is 0.4 mg to 2.0 mg intravenously. Dosages of Narcan 0.125-0.25 mg and 0.2-0.4 mg are too low, whereas 3.0-4.0 mg is too high.
A laboring client has received naloxone (Narcan) intravenously. When should the nurse anticipate the peak effect?
Onset of action for Narcan occurs in two minutes, with its peak effect in 5 to 15 minutes. The duration may be as short as 45 minutes.
8 . Immediately after a cesarean section birth, the anesthesiologist plans to inject a narcotic into the epidural space to provide analgesia for approximately 24 hours. Which opiod should the nurse anticipate that the physician would use?
Duramorph, a form of morphine sulfate, is usually injected into the epidural space after a cesarean section birth to ease the post-operative pain for up to 24 hrs. Narcan is an opiate antagonist used to reverse mild respiratory depression, sedation, and hypotension following small doses of opiates. Nubain and Stadol are narcotic agonists, but are not used in conjunction with an epidural.
The nurse is caring for four laboring clients. Which client would be an appropriate candidate for an epidural block?
When used in active labor, the epidural block may be administered as soon as active labor is established (nullipara is 5 to 6 cm dilated, multipara is 3 to 4 cm ) and the fetal vertex is engaged (zero station), which would be the G3P2 client dilated to 3-4 cm. In a grand-multipara (G5P4) dilated 7-8 cm, there would be insufficient time to place the epidural, as birth is imminent.
The nurse is caring for a laboring client who is scheduled for an epidural block. Which action by the nurse prior to the epidural placement would decrease the chance of maternal hypotension?
Giving a 500 ml fluid bolus prior to the epidural will reduce the chance of maternal hypotension. Monitoring maternal vital signs would not decrease the chance of maternal hypotension. Administering O2 at 5 L/min is appropriate after hypotension has developed to ensure proper oxygenation of the fetus, but it does not impact hypotension. Repositioning the client every hour is a comfort measure that is appropriate throughout the administration of the block.
A 25-year-old client at 18 weeks' gestation has returned to the clinic for her second prenatal visit. Her initial blood pressure was 122/82. Which of the following blood pressure readings should the nurse expect at this visit?
118/76 is the blood pressure the nurse should expect at 18 weeks' gestation. 110/70 is within normal limits (WNL) but too low according to this client's baseline reading. 126/82 and 130/90 are not right because the blood pressure is expected to decrease during pregnancy, reaching its lowest level in the second trimester.
A nurse is teaching a prenatal client about cardiovascular changes during pregnancy. The client asks the nurse why she becomes dizzy when getting out of a chair or out of bed. What rationale should the nurse provide as to the cause of postural hypotension during pregnancy?
Increased blood volume in the lower extremities is the rationale the nurse should provide for the cause of postural hypotension during pregnancy. Hormones, fibrinogen, plasma production and hemoglobin are not related to orthostatic hypotension.
A nurse is assessing a prenatal client's cardiovascular function. At what week should the nurse expect this client's cardiac output (CO) to peak?
Cardiac output (CO) peaks at 20-24 weeks. Thus, 8-10 weeks and 12-18 weeks are too early and 34-38 weeks is too late.
A nurse is teaching a group of first trimester prenatal clients about the discomforts of pregnancy. A client asks the nurse, "What causes my nausea and vomiting?" The nurse knows that _________________________ is the primary contributing factor to first trimester emesis.
The primary cause of prenatal nausea and vomiting is human chorionic gonadotropin. Estrogen stimulates the growth of the uterus and breast tissue. Progesterone prepares the breasts for lactation and decreases uterine contractions. Prostaglandins stimulate uterine contractions.
A nurse is researching the topic of edema during pregnancy. Which of the following contributes to fluid retention?
Increased level of steroid sex hormones contributes to fluid retention during pregnancy. Decreased serum protein influences the fluid balance. Increased intracapillary pressure and permeability influences the fluid balance. Nitrogen retention does not influence fluid balance.
The nurse is taking an intake history of a prenatal client. Which of the following, if detected by the nurse practitioner, would indicate a positive, or diagnostic, sign of pregnancy?
If the nurse practitioner hears the fetal heartbeat with a fetoscope between 17 to 20 weeks' gestation, that would indicate a positive, or diagnostic, sign of pregnancy. The examiner can detect fetal movement at 20 weeks' gestation. Fetal heart movement can be seen as early as eight weeks' gestation with ultrasound. Fetal heartbeat can be detected with the electronic Doppler at 10-12 weeks' gestation.
The nurse in the prenatal clinic assesses a 26-year-old client at 13 weeks' gestation. Which presumptive (subjective) signs and symptoms of pregnancy should the nurse anticipate?
Excessive fatigue and urinary frequency are presumptive (subjective) signs and symptoms of pregnancy. Hegar's sign, ballottement, a positive pregnancy test, Chadwick's sign and uterine souffle are probable (objective) signs or symptoms of pregnancy.
The nurse is researching the topic of uteroplacental blood flow. Which of the following accurately describes funic souffle?
Funic souffle is a soft blowing sound of blood that is at the same rate as the fetal heart rate. Increased blood pulsating through the placenta, a soft blowing sound of blood that is at the same rate as the maternal pulse and increased blood pulsating through the uterine arteries relate to uterine souffle.
The nurse in the prenatal clinic is taking a history from a prenatal client at seven weeks' gestation. The client states, "I don't know if I want this baby. How will I know if I'll be a good mother?" What is the most appropriate response by the nurse?
Not knowing if she wants the baby and wondering if she'll be a good mother is a normal reaction to parenthood in the first trimester. Asking a newly pregnant woman to consider an abortion or adoption.is a nontherapeutic response. The client did not introduce the topic of not wanting her baby. Not knowing if she wants the baby and wondering if she'll be a good mother is a normal reaction to parenthood and not necessarily a sign of depression and does not warrant a referral.
The nurse is teaching a parenting class to prospective fathers. The nurse correctly teaches that the couvade refers to the:
Couvade is the development of the physical symptoms of pregnancy in the father of the baby. The expectant father's fear of hurting the unborn baby during intercourse and transition from nonparent to parent and development of attachment and bonding behaviors in the father of the baby are third trimester paternal concerns.
A client in the prenatal clinic complains of nausea and vomiting. Which intervention should the nurse suggest?
Eating dry crackers or toast before arising in the morning is a good intervention for a client complaining of prenatal nausea. Foods high in fiber help with constipation problems, not nausea. Brushing teeth after meals may trigger vomiting. Taking liquids separate from solids may help by reducing overdistention of the stomach.
A first trimester client in the prenatal clinic complains of nausea and vomiting. Which intervention should the nurse suggest?
It is okay for a first trimester pregnant woman to salt foods to taste. However, highly seasoned foods should be avoided, taking liquids separate from solids may help by reducing overdistention of the stomach, and diets high in protein but low in fat may be helpful.
A prenatal client at 10 weeks' gestation is complaining of leakage of urine. Which self-care strategy should the nurse teach?
Wearing panty liners during the day may help with the urinary leakage that occurs with pregnancy. Fluids should be maintained at 2000 mL, not decreased. The bladder should be emptied every two hours, not every hour (too frequent) or every four hours (not frequent enough).
A prenatal client in the third trimester of pregnancy is diagnosed with varicosities in the vulva and perineum. Which self-care strategy should the nurse teach?
The hips, as well as the feet and legs, must be elevated to promote venous drainage into the trunk. Supportive hose need to be applied in the morning, rather than starting in the afternoon or evening. Changing shoes may help with back pain but not varicosities.
A prenatal client in her third trimester of pregnancy complains of frequent leg cramps. She asks the nurse, "What can I do to prevent these cramps?" Which of the following is the nurse's best response?
Decreasing milk intake to a pint a day and taking calcium carbonate is a good way to prevent leg cramps while in the third trimester of a pregnancy. Increasing milk and dairy servings is not helpful. Changing position and resting often with the feet and legs elevated helps with reduction of venous stasis, not leg cramps.
The nurse is teaching a group of prenatal clients about nipple stimulation in preparation for breastfeeding. For which client is this procedure contraindicated?
A client with a history of preterm labor is not an appropriate candidate for nipple stimulation, as it might trigger uterine contractions. Appropriate clients are the client with enlarged Montgomery's tubercles, the client with active herpetic lesions, or the client with gestational diabetes.
A client in the prenatal clinic asks the nurse how she can toughen her nipples for breastfeeding. Which of the following is the nurse's best response?
Having your partner orally stimulate the nipple is one way to toughen nipples for breastfeeding. Breast shields are effective for women with inverted nipples. Going braless and exposing nipples to sun and air may be helpful. Rolling, not rubbing, the nipples may be helpful.
A nurse is teaching a group of prenatal clients about hazards in the workplace during pregnancy. The nurse correctly teaches that pregnant women who have jobs requiring long periods of standing have a higher incidence of:
Preterm birth is an occupational hazard for women who work standing up for prolonged periods, as there is more uterine stimulation while standing than while sitting or lying down. Neither prolapsed cord, placenta previa nor abruptio placentae are related to prolonged standing.
A nurse is teaching a group of prenatal clients about the importance of exercise during pregnancy. Which client would be the best candidate to continue with her exercise regime?
Exercise would be therapeutic in helping a client with diagnosis of diabetes control her glucose utilization. However, it would be contraindicated in a client with an incompetent cervix and cerclage, in a client with a diagnosis of preeclampsia or in a client with placenta previa.
A prenatal client in her first trimester tells the nurse that she read that hot tubs and saunas are bad for pregnant women. The nurse explains that this is a true statement. Why?
The hyperthermia associated with these activities during the first trimester increases the risk of neural tube defect and mental deficiencies in the neonate. Bacteria in the water are not introduced into the cervix because the mucous plug protects bacteria from entering. There is no relationship between hot tubs and shortness of breath in the mother or causing uterine contractions with preterm labor.