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15 Cards in this Set
- Front
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A client who comes to the clinic to confirm her first pregnancy tells the nurse that she has been experiencing nausea and vomiting. The nurse informs the client that the symptoms should begin to resolve after which week of pregnancy, if not sooner?
12th 14th 16th 18th |
Correct: About half of all pregnant women experience nausea and vomiting during the first trimester of pregnancy. When vomiting persists well into the second trimester and results in weight loss and dehydration, it is considered a complication of pregnancy.Incorrect: Nausea and vomiting that persist well into the second trimester and result in weight loss and dehydration are considered a complication of pregnancy.Incorrect: Nausea and vomiting that persist well into the second trimester and result in weight loss and dehydration are considered a complication of pregnancy.Incorrect: Nausea and vomiting that persist well into the second trimester and result in weight loss and dehydration are considered a complication of pregnancy.
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The nurse monitors the fetal heart rate immediately after the amniotic membranes have ruptured. Which is the rationale for the nurse’s action?
To evaluate the station and presentation To observe for crowning To assess cephalopelvic disproportion To detect fetal distress |
Incorrect: Immediately after the client’s membranes have ruptured, the nurse should assess for fetal distress related to cord compression or prolapse. Rupture of membranes would not immediately affect station and presentation.
Incorrect: Crowning occurs when the fetal head is visible on the perineum. The umbilical cord may prolapse when the membranes rupture, so it is important to monitor the FHR for several minutes to be sure this has not occurred. Rupture of membranes would not cause crowning, although this could occur if birth were precipitous. Even then, it would be important to assess for fetal distress.Incorrect: Cephalopelvic disproportion (CPD) is not assessed directly after rupture of membranes. CPD can contribute to fetal distress, but the CPD itself would not be caused by rupture of membranes. It is a pre-existing condition. The umbilical cord may prolapse when the membranes rupture, so it is important to monitor the FHR for several minutes to be sure this has not occurred. Correct: Fetal heart rate is an indicator of fetal distress or well-being. The umbilical cord may prolapse when the membranes rupture, so it is important to monitor the FHR for several minutes to be sure this has not occurred. |
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A primigravida began her prenatal care at 14 weeks gestation. At that time, the nurse documented the following: weight 140 pounds; BP 110/82; urine protein, negative. Now, at 24 weeks gestation, the nurse reports the following findings: weight 155 pounds; BP 150/100; urine protein, 2+. Which nursing intervention is most appropriate, based on the client’s clinical presentation?
Explore symptoms such as headache and stomach pain. Obtain a clean catch urine specimen. Encourage the client to continue routine prenatal care. Ask the client to provide a 24-hour food diary. |
Correct: Based on the client’s clinical profile, the symptoms clearly suggest pregnancy-induced hypertension. Signs of PIH are headache, vision changes, stomach pain (sign of eclampsia), rapid weight gain and edema of the face and upper extremities.
Incorrect: Obtaining a urine sample is not necessary since the nurse already has assessed that proteinuria has occurred. Incorrect: Based on the client’s signs and symptoms the client is demonstrating signs of pregnancy-induced hypertension (PIH), and will need frequent follow-up if she is not hospitalized. Incorrect: A weight gain this large and rapid at this stage in the pregnancy is probably related to fluid retention, not food intake. Therefore, a food diary is inappropriate. |
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A client gave birth yesterday. Her total 24-hour urine output is 3000 mL. How should the nurse interpret the client’s urine output?
An error has been made in documentation The client is receiving too many fluids The client has a urinary tract infection This is normal postpartum diuresis |
Incorrect: Assuming that there has been an error in documentation is faulty thinking, as there is no evidence to support that assumption. Diuresis is a normal postpartum finding.
Incorrect: Usually the IV is removed shortly after birth when the risk of hemorrhage is decreased. IV fluids are calculated carefully and should not provide excess volume. Incorrect: Urinary tract infections are often seen in the postpartum period related to urinary stasis and insertion of indwelling catheters during labor. However, urinary frequency, not diuresis, is a symptom of UTI. Correct: During pregnancy the client’s blood volume increases about 50%. Within the first 24 hours after birth, there is increased urine output as the body rids itself of excess fluids. Diuresis is normal in the first 24 hours postpartum. |
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A client is in the latent phase of labor. The nurse performing Leopold's maneuvers determines that the fetus is breech with the presenting part not engaged. Which intervention should the nurse implement after notifying the physician of the client's status?
Discuss side-lying and knee-chest positions. Perform an external version procedure. Describe the necessity for an ultrasound of the fetus. Encourage ambulation to assist with fetal descent. |
Correct: Side-lying and knee chest positioning will help with the possible rotation of the fetus from breech to cephalic presentation.
Incorrect: External version is changing the fetal position from breech to cephalic presentation. External versions are performed by a physician or nurse midwife, not the nurse. Incorrect: If Leopold's maneuvers are correct, there is no need for an ultrasound. Incorrect: Normally ambulation would assist the fetal descent, but since the fetus is breech, this is not an appropriate intervention. |
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Which is the rationale for giving insulin rather than oral hypoglycemic agents to clients diagnosed with gestational diabetes? Insulin:
Does not cross the placenta, making it less harmful to the fetus. Is more effective in regulating hyperglycemia throughout the night. Has less potential for producing an antibody response. Given in the first trimester, maintains the fetus' rapid metabolic needs. |
Correct: Oral hypoglycemic agents cross the placenta, unlike insulin, and can be damaging to the fetus. For this reason, insulin is the drug of choice for clients diagnosed with gestational diabetes.
Incorrect: Hypoglycemia, not hyperglycemia, is very common during the night related to the fetus' use of glucose during a time when the woman is not ingesting any food to replenish her blood glucose level. Insulin lowers blood glucose levels, which would exacerbate this problem. Incorrect: Insulin does have the potential for producing an antibody response. Human insulin is used more frequently because it is less likely to produce an antibody response than beef or pork insulin products. Incorrect: Usually insulin needs increase in the second and third trimesters related to the increased metabolic demands of the fetus. Insulin requirements do not increase in the first trimester. |
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A small-for-gestational-age infant has a respiratory rate of 72, nasal flaring, and moderate substernal and intercostal retractions. Which nursing intervention should be delayed?
Instillation of eye ointment Bottle feeding Daily weight Vitamin K injection |
Incorrect: Instillation of the eye ointment must be completed before the baby leaves the delivery room. The only exception to this is if the baby is premature and the eyelids are fused. The baby’s respiratory status will not be affected by the administration of eye ointment.
Correct: Babies who are tachypneic and have respiratory distress should not bottle feed because of risk of aspiration. Babies with respiratory distress are working so hard to breathe that they have poor suck swallow coordination. Incorrect: If the infant requires medication, the dosage is calculated based on the infant’s weight. Daily weights are also necessary if IV fluids are infusing. Therefore, the nurse must weigh the infant, preventing cold stress and over-stimulation which increase the infant's oxygen needs. Incorrect: Vitamin K injections are given regardless of the baby’s respiratory status. |
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A client, 27-weeks gestation, is admitted to the hospital with contractions of moderate intensity, occurring every three to four minutes. The client’s two previous pregnancies ended in preterm labor and fetal death. She is crying and says, “Please help me stop it. It’s happening again!” Which nursing diagnosis is suggested by these data?
Altered role performance related to hospitalization Fear related to unknown outcome of labor Pain related to contractions Hopelessness related to the two previous infant deaths |
Incorrect: The client is not demonstrating altered role performance, which is a disruption in the way the role is perceived. She exhibits the defining characteristics for fear.
Correct: The client has the defining characteristics for fear; it is a realistic fear based on the negative outcome of her last two pregnancies. Incorrect: The client is probably having painful contractions, but the data do not support that; the data are defining characteristics of fear. Incorrect: Crying does not necessarily indicate hopelessness. Hopelessness is a more resigned, passive state than indicated by these data. In a state of hopelessness, the client perceives that there are no alternatives or choices available and cannot mobilize energy on her own behalf. In this scenario, the client is communicating and asking for help. She is expending energy on her own behalf. |
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A client is in active labor. When her membranes rupture spontaneously, a moderate amount of green amniotic fluid is noted. After listening to the fetal heart rate, which should the nurse do next?
Take the client’s temperature. Observe the perineum for crowning. Have the client sign an operative permit. Notify the physician or nurse midwife. |
Incorrect: The amniotic fluid is meconium-stained, which may be a sign of fetal distress. Green fluid is NOT a sign of infection, so taking the client’s temperature is not appropriate.
Incorrect: Crowning is not the cause for the meconium-stained fluid. Incorrect: Having the client sign an operative permit implies that a c-section will be performed. However, the caregivers may elect to monitor the client and deliver vaginally. Meconium-stained fluid is not, by itself, an indicator for c-section. Correct: Notifying the physician or nurse midwife is appropriate because meconium-stained fluid may indicate that there has been fetal distress and may lead to neonatal complications |
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At 8:00 p.m. a client gave birth vaginally. By which time can the nurse expect the placenta to have detached?
8:50 p.m. 8:01 p.m. 8:40 p.m. 8:30 p.m. |
Incorrect: Placental detachment is usually seen about 10 minutes after birth.
Incorrect: Normally the placenta detaches 5-10 minutes after the birth of the baby. This choice is too soon. Incorrect: The average length of time for this stage is 5-10 minutes but it may last up to 30 minutes. Correct: The third stage of labor is the placental separation stage, which begins with the birth of the baby and ends when the placenta is expelled. The normal time for this stage is 5-30 minutes. |
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An infant is delivered by cesarean birth at 38 weeks gestation because of macrosomia and cephalopelvic disproportion. Maternal history reveals diabetes mellitus. Which nursing diagnosis is most appropriate for this infant?
Risk for impaired tissue perfusion related to hyperbilirubinemia secondary to decreased extracellular fluid volume and hemoconcentration Risk for altered nutrition: more than body requirements related to hyperglycemia secondary to loss of transplacental supply of maternal insulin Risk for injury related to hypoglycemia secondary to loss of maternal glucose supply Risk for impaired gas exchange related to respiratory distress syndrome secondary to insufficient pulmonary surfactant |
Incorrect: Hyperbilirubinemia is not an issue in this situation.
Incorrect: The infant is large for gestational age, and is at risk for hypoglycemia, not hyperglycemia. Correct: Infants of diabetic mothers usually have hypoglycemia about an hour after birth related to the loss of maternal glucose. Incorrect: The only data to support this diagnosis is the 38-week gestation period. However, the lungs are not likely to be deficient in surfactant at that age. Because of the mother’s diabetes, the main concern is the baby’s blood glucose level. |
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Immediately after birth, a premature infant is transferred to a distant hospital for care. When the baby’s mother comes to the hospital to visit the baby, which nursing action best promotes bonding?
Position the mother so that the baby can see her. Assist the mother in dressing the baby. Encourage the mother to touch and hold the baby. Encourage the mother to call the baby by name. |
Incorrect: Positioning the baby so it can see the mother is not the most effective method to encourage bonding.
Incorrect: If the baby has monitors and tubing attached to it, dressing the baby is not practical. The nurse should dress the baby in order to be able to quickly assess color and respiratory status while the baby is being handled. Correct: Touching and holding the infant is the best way to promote bonding. Interrupted bonding is a major concern because the baby will have a prolonged hospitalization and is far away from the family. Touching may need to be encouraged because of the tubing and wires, which make parents apprehensive. Also there is a fear of getting too close to the baby only to have it die. Incorrect: Calling the baby by name will help with bonding, but is not as effective as touching. |
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Apgar scores of 3 at one minute and 6 at five minutes are assigned to a postterm infant. The nurse closely monitors the infant for which condition?
Ductus venosus closure Neonatal sepsis Respiratory distress Hypoglycemia |
Incorrect: The clamping of the umbilical cord causes the constriction of the ductus venosus. The nurse usually does not monitor for its closure. Apgar scores reflect the status of heart and respiratory rate, muscle tone, color, and reflex irritability.
Incorrect: It is true that a baby exposed to a TORCH infection may have low Apgars, but the nurse still needs to assess respiratory and cardiac function first. The Apgar score itself does not indicate infection; it only indicates physical signs (i.e., changes in heart and respiratory rate, muscle tone, color, and reflex irritability) that may be caused by infection, prematurity, congenital defects, or any number of other conditions. Correct: Apgar scores range from 0-10. Because the infant is postterm and the Apgars scores are low, the nurse should monitor for signs of respiratory distress (cyanosis, nasal flaring, retractions). Actually, at this point, the low one minute apgar indicates that the baby is likely to be intubated and given positive pressure ventilation with high oxygen concentration. Remember the ABC’ s first: airway, breathing and circulation. Incorrect: Hypoglycemia is not a priority at this point. Apgar scores do not reflect blood glucose level. |
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Why should the nurse closely monitor a premature infant whose body temperature is low?
Cold stress increases the infant’s oxygen consumption. Preterm infants are at risk for hypotension related to vasodilation. Premature infants lose a greater percentage of heat through the head. Vasoconstriction of the blood vessels affects kidney function. |
Correct: Cold stress increases metabolic demands, which increases the need for oxygen and glucose. Hypoxia, acidosis, decreased surfactant production and the collapse of the alveoli are consequences of cold stress. The nurse must observe for respiratory distress as a result of hypothermia.
Incorrect: Cold stress causes the blood vessels to constrict, not dilate. Incorrect: This statement is true, but not the reason why the nurse is closely monitoring the infant. Incorrect: The blood vessels do constrict, but altered kidney function is not usually a consequence. |
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A nursing diagnosis of “risk for altered parenting” is made for a 17-year-old primigravida who is in active labor. Which evidence best supports the nursing diagnosis?
Lack of information related to childbirth Father of child not involved Anxiety about the unknown birth process Client does not speak English |
Incorrect: This supporting evidence best describes knowledge deficit, not altered parenting. Lack of knowledge about child development and care are risk factors for altered parenting, but lack of information about the birth process itself should not be, except perhaps in an indirect way.
Correct: Lack of role identity is a defining characteristic that supports this nursing diagnosis. Other supporting evidence may be related to client’s chronological age or developmental stage, unrealistic expectations, and lack of social supports. Incorrect: Anxiety about birth is often seen and is not a risk factor for altered parenting. Incorrect: This supports a diagnosis of impaired verbal communication. It should not interfere with the client’s ability to parent. |
