3/31 Flashcards
The nurse is assessing a pregnant client at the end of her second trimester. Which clinical finding causes the nurse to suspect preeclampsia?
A. two urine samples showing proteinuria
B. progressive weight gain in the second trimester
C. dependent ankle edema in the late afternoon
D. blood pressure fluctuaions on three consecutive measures
Answer: A
Rationale: three in a row aka three successive
Multisystem issue
Kidneys affected by vasoconstriction
Vasospasms
Always gain weight in second trimester
Dependent ankle edema - normal
A client at 42 weeks’ gestation is admitted for a nonstress test. The nurse concludes that this test is being done because of which possible complication of a prolonged pregnancy?
A. polyhydramnios
B. placental insufficiency
C. postpartum infection
D. subclinical gestational diabetes
Answer: B
Rationale: placenta is old - 42 weeks
Which postpartum client will the nurse assess first?
A. client who vaginally delivered a 7-pound (3175 gm) baby an hour ago
B. client who vaginally delivered a 32-week preterm baby 4 hours ago
C. client who vaginally delivered a 9-pound (4082 gm) baby an hour ago
D. client who had a planned cesarean birth of an 8-pound baby 2 hours ago
Answer: C
Rationale: C-section - 2 hours
Vaginal delivery - bigger baby - risk higher with bigger baby - higher risk with vaginal - suction out so much as well
Preterm baby - baby probably in NICU
7 pound baby - smaller
Which is the initial nursing action when a multipara requisitions something for pain in labor?
A. evaluate the fetal monitor strip to determine the frequency of contractions
B. asking the client if she prefers an epidural or IV pain medications
C. determining the client’s options by reviewing the prescriptions in the chart
D. examining the clien’s cervix for dilation and effacement
Answer: D
Rationale: multipara - had more than one baby
Not review - not know cervix
Determine options after cervix measured because that determines options
Epidural - not know cervix
NEED ALL DATA before get decision
Late decelerations are noted on the fetal monitor strip of a client with an intravenous infusion who received epidural anesthesia 20 minutes ago. Which ction will the nurse take immediately?
A. increase the intravenous flow rate from 125 to 150 mL/hr
B. administer O2 at a rate of 8 to 10 mL/min by way of facemask
C. reposition the client from supine to left lateral
D. assess the maternal BP for systolic below 100 mmHg
Answer: C
Rationale: reposition first; having placental insufficiency - epidural dilating out - perfusion low - not perfusing placenta so BP low and feels icky - HR does late decelerations
Need check BP - before that need reposition because perfusion prob - probably bolus and O2 - to increase BP - first thing is reposition
Least invasive to most invasive
During pregnancy - baby priority
After pregnancy - constriction of uterine muscle
When assessing a client suspected of having a placental abruption, which will the nurse expect to find?
A. uterine tenderness and increased fetal activity
B. bright red blood and multiple clots
C. cessation of contractions and decreased uterine size
D. concealed hemorrhage and FHR accelerations
Answer: A
Rationale: initially hyperactive because losing volume then lose no fetal activity later on
The client is 3 cm, 100% effaced, and the fetal station is -1. Which stage of labor has the client reached?
A. latent
B. First
C. active
D. second
Answer: B
Which intervention will the nurse antipicipate when caring for a pregnant client with a history of cardiac disease?
A. prophylactic antibiotics at the time of birth
B. bed rest during the last trimester
C. preparation for a cesarean birth
D. increasing dosage of cardiac medication
Answer: A
Rationale: bed rest - risk for DVTs
C-section - not necessary; vaginal birth - better and less risk
Increase meds - not necessary
Which assessments and interventions are needed once an epidural catheter is placed? SATA
A. maintain intravenous fluid administration
B. have oxygen available in case of hypotension
C. prepare for indwelling urinary catheter placement
D. position the client supine for easy of monitoring
E. administer an oxytocin infusion to maintain the labor pattern
Answer: A, B, C
Rationale: not do supine; not start pitocin - not necessary
Oxytocin is prescribed for a client in labor after a period of ineffective contractions. Which nursing interventions are most important if strong contractions that last 90 seconds or longer occur? SATA
A. stopping the oxytocin infusion
B. turning the client to her side
C. notifying the PCP
D. administer magnesium sulfate
E. verifying the duration of contractions
Answer: A, B, C, E
Rationale: not need do mag sulfate for strong contractions
Side - helps with perfusion to fetus
Notify doc for big and long contractions
Verify - hands on and palpate intensity of contractions/intrauterine monitor to measure it
