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blurred or double vision
A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to
report to the provider during pregnancy. What info should the nurse include in the teaching?
, decrease the dose of oxytocin by half
The nurse should decrease the dose of oxytocin by half because the client is experiencing
uterine tachysystole.
A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via
continuous IV infusion. The nurse notes that the client is having contractions every 2 min
which last 100-110 seconds that the fetal heart rate is reassuring. What action should the
nurse take?
prepare equipment needed for newborn resuscitation
The nurse should ensure that all supplies and equipment needed for resuscitation of the
newborn are readily available for every delivery. Endotracheal suctioning is recommended in
cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle
tone, and bradycardia after delivery.
A nurse is caring for a client who is in active labor and has meconium staining of the
amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor.
What action should the nurse take?
perform a vaginal exam
When a client has a placenta previa, the placenta implants in the lower part of the uterus and
obstructs the cervical os (the opening to the vagina). The nurse should clarify this
prescription because any manipulation can cause tearing of the placenta and increased
bleeding.
A nurse is reviewing the medical record of a client who is at 33 wks gestation and has
placenta previa and bleeding. What scripts should the nurse clarify with the provider?
use vibroacoustic stim on the client's abd for 3 seconds
The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity
because the fetus is most likely sleeping. Fetal movement should cause accelerations in the
FHR.
A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test.
The FHR is 130 without accelerations for the past 10 min. What action should the nurse take?
, instruct the client to obtain a rubella immunization after delivery
A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that
the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood
type O neg. What action should the nurse take?
fetal GI anomaly
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus.
Gastrointestinal malformations and neurologic disorders are expected findings for a fetus
experiencing the effects of polyhydramnios.
A nurse is reviewing the med record of a client who is at 39 wks gestation and has
polyhydramnios. What finding should the nurse expect?
apply pressure to the client's sacral area during contractions
A nurse is caring for a client who is in the latent phase of labor and is experiencing low back
pain. What action should the nurse take?
feeling of warmth
The nurse should tell the client to expect the feeling of warmth all over her body while the
magnesium sulfate is infusing.
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via
continuous IV infusion about expected adverse effects. What adverse effects should the nurse
include in the teaching?
swelling of the face
A nurse is teaching a client who is at 12 wks gestation about manifestations of potential
complications that she should report to her provider. What info should the nurse include in
the teaching?
you will need to have a full bladder during the ultrasound
MY ANSWER
The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the
pelvis during the examination. Therefore, it is important to ensure that the client has a full
bladder to obtain the most accurate image of the fetus.
, A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in the first
trimester. What info should the nurse include in the teaching?
dark red vaginal bleeding
The nurse should expect the client who has a mild placental abruption to have minimal dark
red vaginal bleeding.
A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What
finding should the nurse expect?
. april 15
A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule,
the nurse should identify the client's estimated DOB as what?
uteroplacental insufficiency
A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor.
The nurse observes late decels in the FHR. What finding should the nurse identify as the
cause of late decels?
urinary output 20 mL/hr
The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate
renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary
output can also indicate a decrease in renal perfusion secondary to a worsening of the client's
pre-eclampsia.
A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate
via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to
the provider?
I should go to the hospital if I think I may be in labor
Cervical cerclage prevents premature opening of the cervix during pregnancy. The client
should immediately go to a facility for evaluation if she experiences any manifestations of
labor while the cerclage is in place. If the client experiences preterm uterine contractions she
might require tocolytic therapy.