The Pregnant Client. A multigravid client at 32 weeks’ gestation has experienced hemolytic disease of the newborn in a past pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following?
1. Placental blood.
2. Amniotic fluid.
3. Fetal blood.
4. Maternal blood.
Correct Answer 2. The division of the abdominal muscles is a frequent occurrence during pregnancy and postpartum, caused by the size of the fetus and influenced by maternal hormones. The nurse should discuss the separation with the client and assure her that no further actions are indicated. Exercises involving the head and shoulders may be initiated after the 6-week checkup to improve the muscle tone of the abdomen, but training will not repair the separation. A referral to a surgeon for surgical repair is the client’s personal choice but would not be medically indicated for the split.
CN: Physiological adaptation; CL: Synthesize
A patient with a past medical history of ventricular septal defect repaired in infancy is consulted at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client’s care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification?
1. Class I.
2. Class II.
3. Class III.
4. Class IV
Correct Answer 3. A real Homan’s sign, discomfort behind the knee or in the upper calf area on dorsiflexion of the foot, may indicate thrombophlebitis. Other signs include edema and redness at the site and maybe more reliable as an indicator of thrombophlebitis. The nurse should inform the physician immediately and ask the client to remain in bed to minimize the risk for pulmonary embolus, a severe consequence of thrombophlebitis should a clot dislodge. The Homan sign is observed on the client’s legs, so placing an ice pack on the perineal area is inappropriate. However, ice to the perineum would be helpful in episiotomy pain and swelling. The client does not need to be positioned in a semi-Fowler’s position but should remain on bed rest to prevent dislodgement of a potential clot.
CN: Reduction of risk potential; CL: Synthesize
A woman who has had asthma since she was a child is under control when the client takes her medication correctly and consistently is now pregnant for the first time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction?
1. “I need to continue taking my asthma medication as prescribed.”
2. “It is my goal to prevent or limit asthma attacks.”
3. “During an asthma attack, oxygen need continuance to be high for mother and fetus.”
4. “Bronchodilators should be used only when necessary because of the risk they present to the fetus.”
Correct Answer 2. A significant complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is familiar with a diagnosis of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary embolism. It also could indicate possible hemorrhage secondary to intravenous heparin therapy. Bradycardia for the first seven days in the postpartum period is standard.
CN: Reduction of risk potential; CL: Synthesize
A woman at 21 weeks’ gestation has right upper quadrant pain radiating to her back. She rates the painting as nine on a scale of 1 to 10 and says that it has occurred two times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client?
1. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy.
2. Refer the client to her health care provider for evaluation and treatment of the pain.
3. Discuss nutritional strategies to decrease the possibility of heartburn.
4. Support the client’s use of acetaminophen (Tylenol) to relieve pain.
Correct Answer 3. A slow pulse (bradycardia) is regular for the first seven days postpartum as the body begins to adjust to the decrease in blood volume and return to the prepregnant state. Adverse effects of heparin therapy suggesting prolonged bleeding involve hematuria, epistaxis, increased lochial flow, and bleeding gums. Typically, tachycardia, not bradycardia, would be associated with bleeding. Petechiae indicate bleeding under the skin or in subcutaneous tissue. CN: Reduction of risk potential; CL: Evaluate
A client in the area at 19 weeks’ gestation says that she has not felt her baby move in the past week, and no fetal heart tones are found. While evaluating this client, the nurse identifies her as at the highest risk of developing which problem?
1. Abruptio placentae.
2. Placenta previa.
3. Disseminated intravascular coagulation.
4. Threatened abortion.
Correct Answer 3. Successful teaching is demonstrated when the patient says, “I should practice a soft toothbrush to brush my teeth.” Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. The use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.
CN: Pharmacological and parenteral therapies; CL: Evaluate