Community Health Nursing and Care of the Mother and Child for your nursing review with rationale. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago.
Results
#1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion?
Inevitable abortion is the termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.
#2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client’s record, would alert the nurse that the client is at risk for a spontaneous abortion?
Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.
#3. Nurse Harold Nactor is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority?
Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock
and controlling pain. An elevated pulse rate is an indicator of shock.
#4. Nurse Yang Qin is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy requires?
Glucose crosses the placenta, but the insulin does not. High fetal demands for glucose, combined with the insulin resistance
caused by hormonal changes in the last half of pregnancy can result in an elevation of maternal blood glucose levels. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy.
#5. Nurse Mei Long Lei is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?
The most common signs and symptoms of hydatidiform mole include elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, and failure to detect fetal heart activity even with sensitive instruments, excessive nausea, and vomiting, and early development of pregnancy-induced hypertension. The fetal activity would not be noted.
#6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is
The absence of patellar reflexes is an indicator of hypermagnesemia, which requires the administration of calcium gluconate.
#7. During vaginal examination of Jessa who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:
Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.
#8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is
Contractions every 1 ½ minute lasting 70-80 seconds, are indicative of hyperstimulation of the uterus, which could
result in injury to the mother and the fetus if Pitocin is not discontinued.
#9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:
A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG)
through administration of calcium gluconate is an essential part of care.
#10. A trial for vaginal delivery after an earlier caesarean, would likely to be given to a gravida, who had
This type of client has no obstetrical indication for a cesarean section as she did with her first cesarean delivery.
