Following an eclamptic seizure, the nurse should assess the client for which of the following?

• Inhaltsverzeichnis Show

  • What are the characteristics of an eclamptic seizure?
  • What happens during an eclamptic seizure?
  • What should a nurse assess for a patient with preeclampsia?
  • What are the clinical signs of an eclamptic fit?

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Pregnant Client with Preeclampsia or Eclampsia + Chronic Hypertension + Third trimester Bleeding + Pre term labor + PROM + Diabetes + Heart Disease + Ectopic pregnancy + Hyperemesis Gravidarum + Hydratiform Mole + Misc. Complications + Quality & Safety

Terms in this set (97)

A 32-year-old multigravida returns to the
clinic for a routine prenatal visit at 36 weeks' gesta-
tion. She has had a prior pregnancy with pregnancy- induced hypertension. The assessments during thisvisit include BP 140/90, P 80, and + 2 edema of the ankles and feet. Based on the client's past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic?

1. Headaches.
2. Blood glucose level.
3. Proteinuria.
4. Edema in lower extremities.

3. Proteinuria.

The nurse is instructing a preeclamptic client
about monitoring the movements of her fetus to
determine fetal well-being. Which statement by the
client indicates that she needs further instruction
about when to call the health care provider concerning fetal movement?

1."If the fetus is becoming less active than before."
2. "If it takes longer each day for the fetus to move 10 times."
3. "If the fetus stops moving for 12 hours."
4. "If the fetus moves more often than 3 times an hour."

4. "If the fetus moves more often than 3 times an hour."

A 29-year-old multigravida at 37 weeks'
gestation is being treated for severe preeclampsia
and has magnesium sulfate infusing at 3 g/hour. The
nurse has determined the priority nursing diagnosis
to be: risk for central nervous system injury related
to hypertension, edema of cerebrum. To maintain
safety for this client, the nurse should:
1. Maintain continuous fetal monitoring.
2. Encourage family members to remain at bedside.
3. Assess reflexes, clonus, visual disturbances, and headache.
4. Monitor maternal liver studies every 4 hours.

3. Assess reflexes, clonus, visual disturbances, and headache.

At 32 weeks' gestation, a 15-year-old
primigravid client who is 5 feet, 2 inches tall has
gained a total of 20 lb, with a 1-lb gain in the last
2 weeks. Urinalysis reveals negative glucose and a
trace of protein. The nurse should advise the client
that which of the following factors increases her risk
for preeclampsia?
1. Total weight gain.
2. Short stature.
3. Adolescent age group.
4. Proteinuria.

3. Adolescent age group.

A primigravid client's baseline blood pres-
sure at her initial visit at 12 weeks' gestation was
110/70 mm Hg. During an assessment at 38 weeks'
gestation, which of the following data would indi-
cate mild preeclampsia?

1.Blood pressure of 160/110 mm Hg on two separate occasions.
2. Proteinuria, more than 5 g in 24 hours.
3. Serum creatinine concentration of 1.4 mL/dL. 4. Weight gain of 2 lb in the last week.

4. Weight gain of 2 lb in the last week.

A 16-year-old client at 34 weeks' gestation,
who is being monitored at home with home nurs-
ing visits, is diagnosed with mild preeclampsia and
has gained 2 lb in the past week. Her current blood
pressure is 144/92 mm Hg. Which assessment fi nd-
ing would require further action by the home health
nurse?
1. Occasional headache.
2. Frequent voiding in large amounts.
3. 1 + pedal edema.
4. 3 + protein on urine dipstick.

3 + protein on urine dipstick.

When developing the teaching plan for a
primigravid client at 30 weeks' gestation diagnosed
with mild preeclampsia who is being treated at
home, which of the following would the nurse identify as the most appropriate client-centered goal?

1.Return visit to the prenatal clinic in approximately 4 weeks.
2. Decreased edema after 1 week of a low- protein, low-fiber diet.
3. Bed rest on the left side during the day, with bathroom privileges.
4. Immediate reporting of adverse reactions to magnesium sulfate therapy.

3. Bed rest on the left side during the day, with bathroom privileges.

After instructing a primigravid client at 38
weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?

1. Hydrocephalic infant.
2. Abruptio placentae.
3. Intrauterine growth retardation.
4. Poor placental perfusion.

3. Intrauterine growth retardation.

After instructing a multigravid client
diagnosed with mild preeclampsia how to keep
a record of fetal movement patterns at home, the
nurse determines that the teaching has been effec-
tive when the client says that she will count the
number of times the baby moves during which of
the following time spans?

1. 30-minute period three times a day.
2. 45-minute period after lunch each day.
3. 1-hour period each day.
4. 12-hour period each week.

3. 1-hour period each day.

When teaching a multigravid client diag-
nosed with mild preeclampsia about nutritional
needs, which of the following types of diet should
the nurse discuss?

1. High-residue diet.
2. Low-sodium diet.
3. Regular diet.
4. High-protein diet.

3. Regular diet.

A 17-year-old client at 33 weeks' gestation
diagnosed with mild preeclampsia is prescribed
bed rest at home. The nurse instructs the client to
contact the health care provider immediately if she
experiences which of the following?

1. Blurred vision.
2. Ankle edema.
3. Increased energy levels.
4. Mild backache.

1. Blurred vision.

One week after her prenatal visit, a primi-
gravid client at 38 weeks' gestation diagnosed with
mild pre-eclampsia calls the clinic nurse complain-
ing of a continuous headache for the past 2 days
accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client:

1. "Take two acetaminophen tablets. They aren't as likely to upset your stomach."
2. "I think the doctor should see you today. Can you come to the clinic this morning?"
3. "You need to lie down and rest. Have you tried placing a cool compress over your head?"
4. "I'll ask the doctor to call in a prescription for aspirin with codeine. What's your pharmacy's number?"

2. "I think the doctor should see you today. Can you come to the clinic this morning?"

When assessing a 16-year-old primigravid
client at 37 weeks' gestation diagnosed with severe
preeclampsia, which of the following indicates the
client needs continued management for the preec-
lampsia?

1. Blood pressure of 138/94 mm Hg.
2. Severe blurring of vision.
3. Less than 2 g of protein in a 24-hour sample.
4. Weight gain of 0.5 lb in 1 week.

2. Severe blurring of vision.

When preparing the room for admission of a
multigravid client at 36 weeks' gestation diagnosed
with severe preeclampsia, which of the following
should the nurse obtain?

1. Oxytocin infusion solution.
2. Disposable tongue blades.
3. Portable ultrasound machine.
4. Padding for the side rails.

4. padding for the side rails.

The physician orders intravenous magnesium
sulfate for a primigravid client at 38 weeks' gesta-
tion diagnosed with severe preeclampsia. Which of
the following medications should the nurse have
readily available at the client's bedside?

1. Diazepam (Valium).
2. Hydralazine (Apresoline).
3. Calcium gluconate.
4. Phenytoin (Dilantin).

3. Calcium gluconate.

For the client who is receiving intravenous
magnesium sulfate for severe preeclampsia, which
of the following assessment findings would alert the nurse to suspect hypermagnesemia?
1. Decreased deep tendon reflexes.
2. Cool skin temperature.
3. Rapid pulse rate.
4. Tingling in the toes.

1. Decreased deep tendon reflexes.

A 28-year-old multigravida at 37 weeks'
gestation arrives at the emergency department with
a blood pressure of 160/104 mm Hg and +3 refl exes
without clonus. The client is diagnosed with severe
preeclampsia. The nurse collaborates with the
health care provider to develop a plan of care that
care will first include:
1.Administration of glucocorticoids (Betame- thasone).
2. Vaginal or cesarean delivery of the fetus.
3. Prevention of seizures with phenytoin (Dilantin).
4. Reduction of fluid retention with thiazides.

2. Vaginal or cesarean delivery of the fetus.

Which of the following would the nurse
identify as the priority to achieve when develop-
ing the plan of care for a primigravid client at 38
weeks' gestation who is hospitalized with severe
preeclampsia and receiving intravenous magnesium
sulfate?

1. Decreased generalized edema within 8 hours.
2. Decreased urinary output during the first 24 hours.
3. Sedation and decreased reflex excitability within 48 hours.
4. Absence of any seizure activity during the first 48 hours.

4. Absence of any seizure activity during the first 48 hours.

The nurse is administering intravenous
magnesium sulfate as ordered for a client at
34 weeks' gestation with severe preeclampsia.
Which of the following are desired outcomes of
this therapy? Select all that apply.
1. T 98, P 72, R 14.
2. Urinary output <30 mL/hr.
3. HR 120 BPM.
4. Fetal heart rate with late decelerations.
5. BP of <140/90.
6.DTR's2+.
7. Magnesium level= 5.6 mg/dL.
8. Clonus = 2+.

1. T 98, P 72, R 14.
3. HR 120 BPM.
5. BP of <140/90.
6. DTR's 2+.
7. Magnesium level= 5.6 mg/dL.

Soon after admission of a primigravid client
at 38 weeks' gestation with severe preeclampsia, the physician orders a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being
administered, which of the following assessment
findings should the nurse report immediately?

1. Respiratory rate of 12 breaths/minute.
2. Patellar reflex of +2.
3. Blood pressure of 160/88 mm Hg.
4. Urinary output exceeding intake.

1. Respiratory rate of 12 breaths/minute.

As the nurse enters the room of a newly
admitted primigravid client diagnosed with severe
preeclampsia, the client begins to experience a
seizure. Which of the following should the nurse do
first?

1. Insert an airway to improve oxygenation.
2. Note the time when the seizure begins and
ends.
3. Call for immediate assistance.
4. Turn the client to her left side.

3. Call for immediate assistance.

After administering hydralazine (Apresoline)
5 mg intravenously as ordered for a primigravid cli-
ent with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:
1. Tachycardia.
2. Bradypnea.
3. Polyuria.
4. Dysphagia.

1. Tachycardia.

A primigravid client with severe preeclamp-
sia exhibits hyperactive, very brisk patellar refl exes
with two beats of ankle clonus present. The nurse
documents the patellar refl exes as which of the
following?

1. 1+.
2. 2+.
3. 3+.
4. 4+.

4+

A 16-year-old unmarried primigravid client
at 37 weeks' gestation with severe preeclampsia
is in early active labor. Her mother is at the bed-
side. The client's blood pressure is 164/110 mm Hg.
Which of the following would alert the nurse
that the client may be about to experience
a seizure?

1. Decreased contraction intensity.
2. Decreased temperature.
3. Epigastric pain.
4. Hyporeflexia.

3. Epigastric pain.

Fifteen minutes after a client experiences an
eclamptic seizure, the nurse should assess the client
for which of the following?

1. Polyuria.
2. Facial flushing.
3. Hypotension.
4. Uterine contractions.

4. Uterine contractions.

A client at 36 weeks' gestation with eclamp-
sia begins to exhibit signs of labor after an eclamptic
seizure. The nurse should assess the client for:

1. Abruptio placentae.
2. Transverse lie.
3. Placenta accreta.
4. Uterine atony.

1. Abruptio placentae.

The nurse is reviewing the chart of a multi-
gravid client at 39 weeks' gestation with suspected
HELLP syndrome. The nurse should notify the
health care provider about which of the following
test results?

1. Platelets 200,000 mm3.
2. Lactate dehydrogenase (LDH) > 200 units/L.
3. Uric acid 3 mg/dL.
4. Aspartate aminotransferase (AST) 15 units/L.

2. Lactate dehydrogenase (LDH) > 200 units/L.

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hyperten- sion. She was treated with methyldopa (Aldomet) before becoming pregnant. When counseling the cli- ent about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?
1. "I need to reduce my caloric intake to 1,200 calories a day."
2. "A regular diet is recommended during preg- nancy."
3. "I should eat more frequent meals if I get heartburn."
4. "I need to consume more fluids and fiber each day."

1. I need to reduce my caloric intake to 1200 calories a day

After instructing a multigravid client at10 weeks' gestation diagnosed with chronic hyper- tension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?

1. "I may develop hyperthyroidism because of my high blood pressure."
2. "I need close monitoring because I may have a small-for-gestational-age infant."
3. "It's possible that I will have excess amniotic fluid and may need a cesarean section."
4. "I may develop placenta accreta, so I need to keep my clinic appointments."

2. "I need close monitoring because I may have a small-for-gestational-age infant."

The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular coagula- tion after delivering a dead fetus. Which findings are the highest priority to report to the health care provider?

1. Activated partial thromboplastin time (APTT) of 30 seconds.
2. Hemoglobin of 11.5 g/dL.
3. Urinary output of 25 mL in the past hour.
4. Platelets at 149,000/mm3.

3. Urinary output of 25 mL in the past hour.

A 24-year-old client, G 3, P 1, at 32 weeks' gestation, is admitted to the hospital because of vaginal bleeding. After reviewing the client's his- tory, which of the following factors might lead the nurse to suspect abruptio placentae?
1. Several hypotensive episodes.
2. Previous low transverse cesarean delivery.
3. One induced abortion.
4. History of cocaine use.

4. hx of cocaine use

When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation (DIC)?
1. Ringer's lactate solution.
2. Fresh frozen platelets.
3. 5% dextrose solution.
4. Warfarin sodium (Coumadin).

2. Fresh frozen platelets.

When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moder- ate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
1. Painless vaginal bleeding.
2. Uterine tetany.
3. Intermittent pain with spotting.
4. Dull lower back pain.

1. Painless vaginal bleeding.

After giving instruction about the cause ofthe vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effec- tive when the client says that the bleeding results from which of the following?
1. Diminished clotting factors.
2. Exposure of maternal blood sinuses.
3. Increased platelet levels.
4. A large-for-gestational-age fetus.

2. Exposure of maternal blood sinuses.

The physician orders whole blood replace- ment for a multigravid client with abruptio placen- tae. Before administering the intravenous blood product, the nurse should first:
39. A client has received epidural anesthesia to control pain during a cesarean section. Place an X over the highest point on the body locating the level of anesthesia expected for a cesarean birth.
40. The nurse should do which of the following actions first when admitting a multigravid client at 36 weeks' gestation with a probable diagnosis of abruptio placentae?
1.Validate client information and the blood product with another nurse.
2. Check the vital signs before transfusing over 5 to 6 hours.
3. Ask the client if she has ever had any aller- gies.
4. Administer 100 mL of 5% dextrose solution intravenously.

1.Validate client information and the blood product with another nurse.

Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?

1. The client will most likely have postpartum blues.
2. Maternal-infant bonding is likely to be difficult.
3. The client's feeling of grief is a normal reaction.
4. This type of delivery was necessary to save the client's life

3. The client's feeling of grief is a normal reaction.

The nurse should do which of the following actions first when admitting a multigravid client at 36 weeks' gestation with a probable diagnosis of abruptio placentae?

1. Prepare the client for a vaginal examination.
2. Obtain a brief history from the client.
3. Insert a large-gauge intravenous catheter.
4. Prepare the client for an ultrasound scan.

3. Insert a large-gauge intravenous catheter.

The health care provider has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. The nurse should assess the client for which of the following outcomes in the next week?
1. The client will develop preeclampsia.
2. The fetus will develop mature lungs.
3. The client will not likely develop preterm labor.
4. The fetus will not develop gestational diabetes.

3. The client will not likely develop preterm labor.

A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?

1. "I need to stay hydrated all the time."
2. "I need to avoid any infections."
3. "I should include frequent rest breaks if we travel."
4. "Changing to filter cigarettes is helpful."

4. "Changing to filter cigarettes is helpful."

A multigravid client at 34 weeks' gestationis being treated with indomethacin (Indocin) to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following?
1. Pulmonary hypertension.
2. Respiratory distress syndrome (RDS).
3. Hyperbilirubinemia.
4. Cardiomyopathy.

1. Pulmonary hypertension.

The nurse is preparing to administer terb- utaline (Brethine) to a multigravid client in preterm labor. Before administering this drug intravenously, the nurse should determine the results of the following?

1. Hematocrit.
2. Weight gain.
3. Urinary output.
4. Heart rate.

4. Heart rate.

In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoan- terior (LOA) position?
1. Near the symphysis pubis.
2. Two inches above the umbilicus.
3. Below the umbilicus on the left side.
4. At the level of the umbilicus.

3. Below the umbilicus on the left side.

The physician orders betamethasone (Celestone) for a 34-year-old multigravid client at 32 weeks' gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks' gesta- tion. The nurse explains that this drug is given for which of the following reasons?
49. When preparing a multigravid client at34 weeks' gestation experiencing preterm laborfor the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which of the following fetal systems?
1. To enhance fetal lung maturity.
2. To counter the effects of tocolytic therapy.
3. To treat chorioamnionitis.
4. To decrease neonatal production of surfactant.

1. To enhance fetal lung maturity.

The nurse is caring for a multigravid cli-ent at 34 weeks' gestation diagnosed with preterm labor. The client has delivered two stillborn infants at 30 weeks' gestation. The client is scheduled for a sonogram before an amniocentesis. Which of the fol- lowing would be a priority nursing diagnosis for the client?
1. Acute pain related to abnormal uterine con- tractions.
2. Anxiety related to diagnostic tests for fetal well-being.
3. Ineffective coping related to hospitalization.
4. Deficient knowledge related to consequences of preterm birth.

2. Anxiety related to diagnostic tests for fetal well-being.

When preparing a multigravid client at34 weeks' gestation experiencing preterm laborfor the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which of the following fetal systems?

1. urinary
2. gastrointestinal
3. cardiovascular
4. pulmonary

4. pulmonary

The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. Which of the following would the nurse expect the physician to order?
1. Frequent assessments of cervical dilation.
2. Intravenous oxytocin administration.
3. Vaginal culture for Neisseria gonorrhoeae.
4. Sonogram for amniotic fluid volume index.

3. Vaginal culture for Neisseria gonorrhoeae.

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which of the following colors?
1. Yellow.
2. Green.
3. Blue.
4. Red.

3. Blue.

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
1. Red blood cell count.
2. Degree of discomfort.
3. Urinary output.
4. Temperature.

4. Temperature.

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests posi- tive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; tempera- ture, 100° F (37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the physician to order? 1. Intravenous penicillin.
2. Intravenous gentamicin sulfate (Garamycin).
3. Intramuscular betamethasone (Celestone).
4. Intramuscular cefaclor (Ceclor).

1. Intravenous penicillin.

A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the home health nurse. After instruction about care while at home, which of the following client state- ments indicates effective teaching?

1. "It is permissible to douche if the fluid irritates my vaginal area."
2. "I can take either a tub bath or a shower when I feel like it."
3. "I should limit my fluid intake to less than 1 quart daily."
4. "I should contact the doctor if my temperature is 100.4° F or higher."

4. "I should contact the doctor if my temperature is 100.4° F or higher."

A primigravid client at 34 weeks' gestationis experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?

1. Check the status of the fetal heart rate.
2. Turn the client to her right side.
3. Test the leaking fluid with nitrazine paper.
4. Perform a sterile vaginal examination.

1. Check the status of the fetal heart rate.

A client with gestational diabetes who is entering her third trimester is learning how to moni- tor her fetus's movements. After teaching the cli-ent about the kick count, the nurse should provide further instruction if the client makes which of the following statements?

1. "The baby may be more active at different times of the day."
2. "How I feel my baby move is different than my friend."
3. "The baby should be moving less than 10 times in 3 hours."
4. "The baby may not move at times because it is asleep."

3. "The baby should be moving less than 10 times in 3 hours."

A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. The nurse should tell the client that the test results indicate which of the fol- lowing?
1. A contraction stress test is necessary.
2. The nonstress test should be repeated.
3. Chorionic villus sampling is necessary.
4. There is evidence of fetal well-being.

4. There is evidence of fetal well-being.

A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following?
1. Frequent late decelerations.
2. Decreased fetal movement.
3. Inconsistent late decelerations.
4. Lack of fetal movement.

3. Inconsistent late decelerations.

Which of the following statements abouta fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes?

1. It determines fetal lung maturity
2. it is noninvasive using real-time ultrasound
3. It will correlate with the newborn's apgar score
4. It requires the client to have an empty bladder

2. it is noninvasive using real-time ultrasound

A 30-year old multigravida client at 8 weeks gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs during the first trimester?

1. They will increase.
2. They will decrease.
3. They will remain constant.
4. They will be unpredictable.

2. They will decrease.

he nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year his- tory of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching?
1. Candida albicans infection.
2. Twin-to-twin transfer.
3. Polyhydramnios.
4. Preeclampsia.

2. Twin-to-twin transfer.

When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, which of the following would the nurse expect to include as a desired target range for blood glucose levels?

1. 40 to 60 mg/dL between 2:00 and 4:00 p.m.
2. 60 to 100 mg/dL before meals and bedtime snacks.
3. 110 to 140 mg/dL before meals and bedtime snacks.
4. 140 to 160 mg/dL 1 hour after meals.

2. 60 to 100 mg/dL before meals and bedtime snacks.

When teaching a primigravid client with diabetes about common causes of hyperglycemia during pregnancy, which of the following would the nurse include?
1. Fetal macrosomia.
2. Obesity before conception.
3. Maternal infection.
4. Pregnancy-induced hypertension.

3. Maternal infection.

After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia, the nurse determines that the client understands the instruction when she says that hyperglycemia may be manifested by which of the following?
1. Dehydration.
2. Pallor.
3. Sweating.
4. Nervousness.

1. Dehydration.

At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean delivery. The nurse explains to the client that delivery helps to prevent which of the following?
1. Neonatal hyperbilirubinemia.
2. Congenital anomalies.
3. Perinatal asphyxia.
4. Stillbirth.

4. Stillbirth.

A primigravid client with diabetes at39 weeks' gestation is seen in the high-risk clinic. The physician estimates that the fetus weighs at least 4,500 g (10 lb). The client asks, "What causes the baby to be so large?" The nurse's response is based on the understanding that fetal macrosomia is usually related to which of the following?
1. Family history of large infants.
2. Fetal anomalies.
3. Maternal hyperglycemia.
4. Maternal hypertension.

3. Maternal hyperglycemia.

With plans to breast-feed her neonate, a pregnant client with insulin-dependent diabetes asks the nurse about insulin needs during the post- partum period. Which of the following statements about postpartal insulin requirements for breast- feeding mothers should the nurse include in the explanation?
1. They fall significantly in the immediate postpartum period.
2. They remain the same as during the labor process.
3. They usually increase in the immediate postpartum period.
4. They need constant adjustment during the first 24 hours.

1. They fall significantly in the immediate postpartum period.

After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart dis- ease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching?

1."I should avoid being near people who have a cold."
2. "I may be given antibiotics during my pregnancy."
3. "I should reduce my intake of protein in my diet."
4. "I should limit my salt intake at meals."

3. "I should reduce my intake of protein in my diet."

While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her physi- cian immediately if the client experiences which of the following?
1. Mild ankle edema.
2. Emotional stress on the job.
3. Weight gain of 1 lb in 1 week.
4. Increased dyspnea at rest.

4. Increased dyspnea at rest.

When developing the collaborative plan of care with the health care provider for a multigravid client at 10 weeks' gestation with a history of car- diac disease who was being treated with digitalis therapy before this pregnancy, the nurse should instruct the client about which of the following regarding the client's drug therapy regimen?
1. Need for an increased dosage.
2. Continuation of the same dosage.
3. Switching to a different medication.
4. Addition of a diuretic to the regimen.

2. Continuation of the same dosage.

Which of the following anticoagulants would the nurse expect to administer when caring for a primigravid client at 12 weeks' gestation who has class II cardiac disease due to mitral valve stenosis? 1. Heparin.
2. Warfarin (Coumadin).
3. Enoxaparin (Lovenox). ■
4. Ardeparin (Normiflo).

1. Heparin.

A primigravid client with class II heart dis- ease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low- sodium, 1,800-calorie diet. Which of the following instructions should the nurse give the client?
1. Avoid folic acid supplements to prevent megaloblastic anemia.
2. Severely restrict sodium intake throughout the pregnancy.
3. Take iron supplements with milk to enhance absorption.
4. Increase caloric intake to 2,200 calories daily to promote fetal growth.

4. Increase caloric intake to 2,200 calories daily to promote fetal growth.

On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the physi- cian immediately because of the possibility of:
1. Ectopic pregnancy.
2. Abruptio placentae.
3. Gestational trophoblastic disease.
4. Complete abortion.

1. Ectopic pregnancy.

The nurse is assessing a multigravida client at 12 weeks' gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which of the following should the nurse obtain about the client's history? Select all that apply.
1. History of sexually transmitted infections.
2. Number of sexual partners.
3. Last menstrual period.
4. Cesarean section.
5.IUDuse.
6. Contraceptive use.

1. History of sexually transmitted infections.
2. Number of sexual partners.
3. Last menstrual period.
5.IUDuse.
6. Contraceptive use.

Before surgery to remove an ectopic preg- nancy and the fallopian tube, which of the follow- ing would alert the nurse to the possibility of tubal rupture?
1. Amount of vaginal bleeding and discharge.
2. Falling hematocrit and hemoglobin levels.
3. Slow, bounding pulse rate of 80 bpm.
4. Marked abdominal edema.

2. Falling hematocrit and hemoglobin levels.

A multigravid client diagnosed with a prob- able ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess?
1. Uterine cramping.
2. Abdominal distention.
3. Hemoglobin and hematocrit.
4. Pulse rate

4. Pulse rate

A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic preg- nancy. When obtaining the client's history, which of the following would be most important to identify as a predisposing factor?
1. Urinary tract infection.
2. Marijuana use during pregnancy.
3. Episodes of pelvic inflammatory disease.
4. Use of estrogen-progestin contraceptives.

3. Episodes of pelvic inflammatory disease.

After surgery to remove a ruptured fallopian tube, a multigravid client receives discharge instructions about potential complications to report to her physi- cian. Which of the following, if stated by the client as a complication, indicates a need for additional teaching?
1. Pain.
2. Headache.
3. Fever.
4. Bleeding.

2. Headache.

A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse antic- ipates that, because the client's fallopian tube has not yet ruptured, which of the following may be ordered?
1. Progestin contraceptives (Hylutin).
2. Medroxyprogesterone (Depo-Provera).
3. Methotrexate.
4. Dyphylline (Dilor).

3. Methotrexate.

After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which of the follow- ing client statements indicates the need for addi- tional teaching?
1. "I'll eat dry crackers or toast before arising in the morning."
2. "I'll drink adequate fluids separate from my meals or snacks."
3. "I'll eat two large meals daily with frequent protein snacks."
4. "I'll snack on a small amount of carbohy- drates throughout the day."

3. "I'll eat two large meals daily with frequent protein snacks."

A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that "she has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which of the following?
1. Hypercalcemia.
2. Hypobilirubinemia.
3. Hypokalemia.
4. Hyperglycemia.

3. Hypokalemia.

A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravi- darum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which of the following hormones?
1. Progesterone.
2. Estrogen.
3. Somatotropin.
4. Aldosterone.

2. Estrogen.

A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth (NPO) status and is receiving intravenous (IV) fluid replacement therapy. In plan- ning this client's care, the nurse should collaborate with the health care provider (HCP) to carry out which of the following?
1. Withhold oral fluids indefinitely until acido- sis is corrected.
2. Give oral fluids in small quantities whenever the client desires.
3. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.
4. Withhold oral fluids until total parenteral nutrition replaces lost electrolytes.

3. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.

A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should pre- pare to do which of the following?
1. Transfer the client to the antenatal unit.
2. Keep the client NPO for 24 hours.
3. Administer magnesium sulfate.
4. Obtain an ultrasound.

4. Obtain an ultrasound.

A 38-year-old client at about 14 weeks' gesta- tion is admitted to the hospital with a diagnosisof complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which of the following?
1. Pregnancy-induced hypertension. 2. Gestational diabetes.
3. Hypothyroidism.
4. Polycythemia.

1. Pregnancy-induced hypertension

After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
1. Urinary tract infection.
2. Hemorrhage.
3. Abdominal distention.
4. Chorioamnionitis.

2. Hemorrhage.

When preparing a multigravid client whohas undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says thatshe is at risk for developing which of thefollowing?
1. Ectopic pregnancy.
2. Choriocarcinoma.
3. Multifetal pregnancies.
4. Infertility.

2. Choriocarcinoma.

After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid cli- ent asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the fol- lowing time spans?
1. 6 months.
2. 12 months.
3. 18 months.
4. 24 months.

2. 12 months.

The nurse is working with four clients onthe obstetrical unit. Which client will be the highest priority for a cesarean section?
1. Client at 40 weeks' gestation whose fetus weighs 8 lb by ultrasound estimate.
2. Client at 37 weeks' gestation with fetus in ROP position.
3. Client at 32 weeks' gestation with fetus in breech position.
4. Client at 38 weeks' gestation with active herpes lesions.

4. Client at 38 weeks' gestation with active herpes lesions

The nurse notices that a client who has just delivered her infant is short of breath, ashen in color, and begins to cough. She becomes limp on the delivery table. At last assessment 1⁄2 hour ago, her tempature was 98, pulse 78, respirations 16. Deter- mine the nursing actions in the order they should occur.

1. Open airway using head tilt-chin lift.
2. Ask staff to activate emergency response system.
3. Establish unresponsiveness.
4. Give 2 breaths.
5. Check the pulse

3, 2,1,4,5

A client in sickle cell crisis has been hos- pitalized during her pregnancy. After giving dis- charge instructions, the nurse determines the client needs further teaching when she states which of the following?
1. "I will need more frequent appointments during the remainder of the pregnancy."
2. "Signs of any type of infection must be reported immediately."
3. "At the earliest signs of a crisis, I need to seek treatment."
4. "I have this disease because I don't eat enough food with iron."

4. "I have this disease because I don't eat enough food with iron."

A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:

1. Place gentle pressure upward on the fetal head.
2. Place the cord back into the vagina to keep it moist.
3. Begin oxygen by face mask at 8 to 10 L/min.
4. Turn the client on her left side.

1. Place gentle pressure upward on the fetal head.

A client has just had a cesarean section fora prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? Select all that apply.
1. −2 station.
2. Low birth weight infant.
3. Rupture of membranes.
4. Breech presentation.
5. Prior abortion.
6. Low lying placenta.

1. −2 station.
2. Low birth weight infant.
4. Breech presentation
6. Low lying placenta.

A woman who has delivered a healthy new- born is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemor- rhage and notify the healthcare provider about?
1. Bleeding that becomes lighter each day
2. Clots the size of golf balls
3. Saturating a pad in an hour
4. Lochia that last longer than 1 week

3. Saturating a pad in an hour

A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will recieve RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:
1. "RhoGAM will protect my next baby if it is Rh-negative."
2. "RhoGAM will prevent antibody formation in my blood."
3. "RhoGAM will be given to prevent German measles."
4. "RhoGAM will be used to prevent bleeding in my newborn."

2. "RhoGAM will prevent antibody formation in my blood."

A client at 4 weeks postpartum tells thenurse that she can't cope any longer and is over- whelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for?
1. Postpartum blues.
2. Postpartum depression.
3. Poor bonding.
4. Infant abuse.

2. Postpartum depression.

The nurse and a nursing assistant are caring for clients in a birthing center. Which of the follow- ing tasks should the nurse delegate to the nursing assistant? Select all that apply.
1. Removing a Foley catheter from a preeclamptic client.
2. Assisting an active labor client with breathing and relaxation.
3. Ambulating a post cesarean client to the bathroom.
4. Calculating hourly I.V. totals for a preterm labor client.
5. Intake and output catheterization for culture and sensitivity.
6. Calling a report of normal findings to the health care provider.
7. Removing lunch trays and documenting lunch intake.

2,3,7

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
1. A client at 13 weeks' gestation experiencing nausea and vomiting three times a day with +1 ketones in her urine.
2. A client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day.
3. A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.
4. A primigravida at 17 weeks' gestation com- plaining of not feeling fetal movement at this point in her pregnancy.

3. A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.

The nurse is planning care for a group of preg- nant clients. Which of the following clients should be referred to a health care provider immediately?

1. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine.
2. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly.
3. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.
4. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.

3. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.

A client with pregnancy-induced hyper- tension is to receive magnesium sulfate to run at3 grams per hour with normal saline to maintainthe total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncom-ing nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last.

1. Notify the physician of the incident.
2. Assess the client's current status
3. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.
4. Initiate an incident report.

3, 2, 1, 4

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
1. Call for immediate assistance.
2. Turn the client to her side.
3. Note the time when the seizure began.
4. Maintain airway.

1,4,2,3

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