A primigravid client at 16 weeks’ gestation has had an amniocentesis and has received instruction concerning signs and symptoms to report. Which statement indicates that the client needs further education?
A. “I necessitate to call if I start to leak fluid from my vagina.”
B. “If I start bleeding, I will want to call back.”
C. “If my baby does not move, I need to call my health care provider.” correct answer
D. “If I start running a fever, I should let the office know.”
Rationale C. At 16 weeks gestation, a primipara will not feel the baby moving. Quickening occurs between 18 and 20 weeks gestation for a primipara and between 16 and 18 weeks gestation for a multipara. Leaking fluid from the vagina should not occur until labor begins and may indicate a rupture of the membranes. Bleeding and fever are complications that warrant further evaluation and should be reported at any time during the pregnancy.
CN: Health promotion and maintenance; CL: Evaluate
During a visit to the prenatal clinic, a pregnant client at 32 weeks gestation complains of heartburn. The client needs further instruction when she says she must do what?
A. Avoid highly seasoned foods.
B. Avoid laying down right after eating.
C. Eat small, frequent meals.
D. Consume liquids only between meals. correct answer
Rationale D: Consuming most liquids between meals rather than at the same time as eating is an excellent strategy to deter nausea and vomiting in pregnancy but does not relieve heartburn. During the third trimester, progesterone causes relaxation of the sphincter, and the pressure of the fetus against the stomach increases the potential of heartburn. Avoiding highly seasoned foods, remaining upright after eating, and eating small, frequent meals are strategies to prevent heartburn.
CN: Physiological adaptation; CL: Evaluate
The nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia?
A. “I will need to take iron supplements now.”
B. “I may have anemia because my family is of Asian descent.” correct answer
C. “I am considered anemic if my hemoglobin is below 11 g/dL.”
D. “The workload on my heart is increased when there is not enough oxygen in my system.”
Rationale B. Iron deficiency anemia is caused by insufficient iron stores in the body, poor iron content in the pregnant woman’s diet, or both. Other thalassemias and sickle cell anemia, rather than iron deficiency anemia, can be associated with ethnicity but occur primarily in African American or Mediterranean clients. Because red blood cells increase by about 50% during pregnancy, many clients need to take supplemental iron to avoid iron deficiency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dL. In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells.
CN: Reduction of risk potential; CL: Evaluate
Following a positive pregnancy test, a client starts discussing the changes in the next several months with the nurse. The nurse should cover which of the following information about changes the client can anticipate in the first trimester?
A. Differentiating the self from the fetus.
B. Enjoying the role of nurturer.
C. Preparing for the reality of parenthood.
D. Experiencing ambivalence about pregnancy.
Rationale D. Many women in their first trimester feel ambivalent about being pregnant because of the significant life changes for most women who have a child. Ambivalence can be expressed as a list of positive and negative outcomes of having a child, consideration of financial and social implications, and possible career changes. During the second trimester, the infant becomes a separate individual from the mother. The mother will begin to enjoy the role of nurturer postpartum. During the third trimester, the mother begins to prepare for parenthood and all of the tasks that parenting includes.
CN: Health promotion and maintenance; CL: Apply
An antenatal primigravid client has just been notified that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy.
Does the nurse realize the client needs further instruction when she indicates that carrying twins puts her at risk for the following?
A. Preterm labor.
B. Twin-to-twin transfusion.
C. Anemia.
D. Group B Streptococcus.
Rationale D. Group B Streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a significant factor initiating preterm labor, is more likely with twin gestation. The normal uterus can only distend to a certain point, and when that point is reached, the delivery may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestations. The donor twin may become growth restricted and have oligohydramnios, while the recipient twin may become polycythemic and produce heart failure with polyhydramnios. Anemia is a common problem with multiple gestation clients. The mother is commonly unable to consume enough protein, calcium, and iron to supply her needs and those of the fetuses. A maternal hemoglobin level below 11 g/dL is considered anemic.
CN: Physiological adaptation; CL: Evaluate
A 31-year-old multigravid patient has missed three periods and now attends the prenatal clinic because she thinks she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and stomach. These assessments
findings reflect this woman is experiencing a cluster of which signs of pregnancy?
A. Positive.
B.Probable.
C. Presumptive.
D. Diagnostic.
Rationale B. The plan of care should reflect that this woman is experiencing probable signs of pregnancy. She may be pregnant, but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, other disease processes, and pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound confirmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word “diagnostic” is not used to describe the condition of pregnancy.
CN: Physiological adaptation; CL: Analyze
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