1. A 38-week primigravida who works as a secretary and sits at a computer for 8
hours each day tells the nurse that her feet have begun to swell. Which
instruction would be most effective in preventing pooling of blood in the lower
extremities?
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will
straighten out the pelvic veins and increase venous return.
2. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks
gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine)
0.25 mg subcutaneously to stop her labor contractions. The nurse plans to
monitor for which primary side effect of terbutaline sulfate?
Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-
adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic
agonist properties of the drug may cause tachycardia, increased cardiac output,
restlessness, headache, and a feeling of "nervousness".
,3. What does a diaphragmatic hernia look
like? Scaphoid abdomen and anorexia
4. A new mother is afraid to touch her baby's head for fear of hurting the "large soft
spot." Which explanation should the nurse give to this anxious client?
There's a strong, tough membrane there to protect the baby so you need not
be afraid to wash or comb his/her hair.
5. A client who is attending antepartum classes asks the nurse why her
healthcare provider has prescribed iron tablets. The nurse's response is
based on what knowledge?
It is difficult to consume 18 mg of additional iron by diet alone.
Consuming enough iron-containing foods to facilitate adequate fetal storage of
iron and to meet the demands of pregnancy is difficult so iron supplements are
often recommended.
6. What is megaloblastic anemia caused
by? folic acid deficiency
7. A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask
when she could use a home pregnancy test to diagnose pregnancy. Which
response is best?
A home pregnancy test can be used right after your first missed period.
, Home urine tests are based on the chemical detection of human chorionic
gonadotrophin, which begins to increase 6 to 8 days after conception and
is best detected at 2 weeks’gestation or immediately after the first missed
period.
8. A 28-year-old client in active labor complains of cramps in her leg. What
intervention should the nurse implement?
, Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the
client is capable) and putting the heel of the foot on the floor is the best means of
relieving leg cramps.
9. A client at 30-weeks’gestation, complaining of pressure over the pubic area, is
admitted for observation. She is contracting irregularly and demonstrates
underlying uterine irritability. Vaginal examination reveals that her cervix is
closed, thick, and high. Based on these data, which intervention should the nurse
implement first?
Obtaining a urine analysis should be done first because preterm clients with
uterine irritability and contractions are often suffering from a urinary tract
infection, and this should be ruled out first.
10. A client in active labor is admitted with preeclampsia. Which assessment finding
is most significant in planning this client's care?
A 4+ reflex in a client with pregnancy-induced hypertension indicates
hyperreflexia, which is an indication of an impending seizure.
11. What is Epogen for?
Changes an apical heart rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
resulting in an increase in RBCs. Since the body has not had to compensate for
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