Implantation Can Cause Bleeding When Menses Would Otherwise Be Expected

A teenage client comes to a prenatal clinic because her menses is 1 week late. Further assessment shows that the client is 8 weeks pregnant and that she experienced a short period of light bleeding 3 weeks ago. The nurse explains to the client that: Correct: Implantation of the conceptus in the endometrium often causes a small amount of bleeding at the site. Implantation bleeding can be mistaken for a light menstrual period, as it occurs around the same time a period would occur, had the client not become pregnant.Incorrect: It is better to simply explain, without making any judgment on the client's own assessment of the situation, that implantation bleeding can appear to be a menstrual period.Incorrect: Bleeding is not expected during pregnancy. It must always be reported to the health care provider because it is often a sign of a complication.Incorrect: There are a number of reasons why bleeding can occur during pregnancy. Some warrant little concern, while others are signs of complications and must be reported immediately. implantation can cause bleeding when menses would otherwise be expected. she is mistaken because the examination is more accurate. some women continue to experience bleeding throughout pregnancy. she is an exception because most often there is no bleeding during pregnancy. 2

When planning to teach a client about feeding her newborn, it is most important for the nurse to assess the mother's: Incorrect: In many instances, cultural beliefs help shape behavior, but they might not be a major influence for the specific client the nurse plans to teach.Incorrect: People significant in a mother's social support network can influence her choices, but regardless of these influences, she still needs to learn how to feed her baby.Correct: Previous experience influences her belief about feeding methods and techniques and helps the nurse determine which information to present and discuss.Incorrect: Infant feeding choices are complex and knowledge is only one component of the decision to breast- or to bottle-feed. cultural background. social support network. personal experience with feeding infants. knowledge about the benefits of breastfeeding. 3

When completing a prenatal health history, the nurse identifies any risk factors for toxoplasmosis and counsels the client about prevention. A major risk factor for contracting this infection is: Incorrect: Intimate contact with an infected person is a means of contracting other TORCH infections for which pregnant women are screened, such as cytomegalovirus. But it is not a primary means of contracting toxoplasmosis.Correct: Poor hand washing after handling infected cat litter is a risk factor for toxoplasmosis infection, one of the TORCH infections for which pregnant women are screened. First-trimester toxoplasmosis infection is often subclinical in the pregnant woman, but can result in fetal damage and spontaneous abortion.Incorrect: Breathing in the exhaled air of an infected person is a means of contracting another TORCH infection for which pregnant women are screened - rubella. But toxoplasmosis is not spread by inhaling droplets of the nose and throat secretions of an infected person.Incorrect: Contact with bird feces or with the dust that accumulates in birdcages can cause psittacosis, a relatively rare infection. Acquired during pregnancy, the pregnant woman can develop a severe, progressive, febrile illness, with headache, disseminated intravascular coagulation, abnormal liver enzyme studies, and impaired renal function. Contact with birds, however, is not a primary means of contracting toxoplasmosis. kissing an infected person. contact with the feces of infected cats. being in close proximity to an infected person. contact with the feces of infected birds. 4

A newborn delivered 15 minutes ago has mild respiratory distress. Short-term, the nurse should prepare to provide: Incorrect: Intubation is required only when a newborn has severe respiratory distress. In any case, however, intubation equipment should always be available and ready for use in neonatal settings.Incorrect: Tactile stimulation is used to elicit crying initially and at any time to interrupt periods of apnea. Mild respiratory distress is unlikely to improve with tactile stimulation.Incorrect: Infants with respiratory distress can be hypoglycemic, and blood glucose will be checked, but it is not the nurse's highest-priority intervention for this newborn at this time.Correct: Cold stress increases the amount of oxygen that the newborn needs. Hypothermia in a newborn can lead to metabolic acidosis, hypoxia, and shock. It is the nurse's priority, after initial stimulation and airway clearance, to provide a neutral thermal environment for this infant. intubation equipment. tactile stimulation. oral dextrose. thermal support. 5

A nurse counsels a client diagnosed with mastitis. The nurse teaches the client that it is absolutely essential to drink adequate amounts of fluid to: Incorrect: Increasing fluids does not keep body temperature down; it replaces fluids lost when body temperature and fluid losses are higher.Incorrect: The baby would have to increase his fluid intake to prevent or resolve constipation. Colostrum and breast milk are easier for a baby to digest, so constipation is less of a problem for breastfed babies. In addition, this issue is unrelated to mastitis.Correct: Maintaining a brisk flow through the affected breast ducts helps diminish the clogs that can contribute to harboring pathogens. An intake of 2 to 3 liters per day is recommended for clients who have mastitis.Incorrect: Drinking enough fluids to quench thirst is not enough to overcome dehydration. Any infection increases fluid losses, so drinking enough to quench thirst is not enough fluid to help treat an infection. keep her temperature down. prevent constipation in her baby. keep milk moving through the affected ducts. keep her from feeling thirsty.

6 Which food would a nurse recommend to a pregnant client to increase the absorption of supplemental iron?

A nurse instructing a pregnant client about what to expect during pregnancy must also advise her to report which symptom to her health care provider immediately? Incorrect: This is a common problem during late pregnancy due to the enlarged uterus creating pressure on the diaphragm, thus decreasing vital capacity.Correct: Severe and persistent headaches can be an indicator of preeclampsia, a potentially serious hypertensive disorder.Incorrect: Leg cramps are a common discomfort during late pregnancy, probably due to the increased weight of the uterus creating pressure on the nerves supplying the lower extremities.Incorrect: Heartburn is a common development during pregnancy, probably as a result of the displacement of the stomach by the growing uterus. Other contributing factors are increased progesterone production and decreased intestinal motility. Shortness of breath Persistent headaches Leg cramps Persistent heartburn 8

A multipara has been in the active phase of labor for the past 8 hours. She is dilated to 6 cm and is 90% effaced. The presenting part remains at a -3 station despite oxytocin augmentation. The nurse should suspect: Correct: The client has been in the active phase of labor longer than average for a multipara. She has dilated and effaced, and she has had the help of oxytocin to ensure adequate labor. Yet the presenting part has not moved down as expected. These are classic findings with cephalopelvic disproportion.Incorrect: Breech presentation does not prevent the presenting part from descending into the pelvis.Incorrect: There is no indication that her labor is hypotonic, especially considering that she has had oxytocin administered.Incorrect: Oligohydramnios does not prevent the presenting part from descending. cephalopelvic disproportion. breech presentation. hypotonic labor. oligohydramnios. 9

A nurse is counseling an adolescent who has just learned that she is pregnant. The nurse conducts a nutritional assessment with careful attention to the client's dietary intake of: Correct: Adolescents are more likely to be anemic due to inadequate iron intake than older women are.Incorrect: Pregnant women need additional protein in their diets, but most Americans consume adequate amounts of protein. The nurse would, of course, carefully assess a client from another culture accordingly.Incorrect: Most women do not have to restrict their sodium intake during pregnancy; therefore, their sodium intake does not require careful assessment.Incorrect: Although about a third of adolescents are underweight before they become pregnant, most Americans eat adequate amounts of carbohydrates. Underweight pregnant adolescents should gain weight with balanced diets, not with diets high in fats and carbohydrates like refined sugar. The nurse would, of course, carefully assess a client from another culture accordingly. iron. protein. sodium. carbohydrates. 10

A nurse recognizes that her client has developed a postpartum infection. As she determines an appropriate plan of care, she sets which long-term goal with her client? Correct: Sepsis and septic shock are consequences of a postpartum infection that is not managed optimally.Incorrect: This is a nurse-centered statement and therefore inappropriately worded for a goal. Plus, checking a client's vital signs is an intervention, not a goal.Incorrect: This is a nurse-centered statement and therefore inappropriately worded for a goal. Plus, teaching self-assessment to a client is an intervention, not a goal.Incorrect: This is a client-centered statement and it is a good short-term goal. However, it is not appropriate as part of a longer-range, more holistic plan. The client's infection will resolve without sepsis or septic shock. The nurse will check the client's temperature every 4 hours. The nurse will teach the client what a normal temperature should be. The client will wash her hands after changing her perineal pads.

A nurse is admitting a client with multiple gestation who is in her first stage of labor. Assessing the fetal heart tracings, the nurse concludes that immediate medical attention is warranted when she identifies: Incorrect: These are normal fetal heart tracings for fetus A and fetus B. Accelerations are periodic increases in fetal heart rate due to fetal movement. Short-term and long-term variability represent normal functioning of the fetal central nervous system.Incorrect: Fetus A has a normal heart rate and early decelerations are from head compression during labor. It is not uncommon to be able to detect only one fetal heartbeat in multiple gestations if one baby is positioned behind the other one in utero.Correct: Fetus A is showing beginning signs of fatigue with decreased heart rate (normal fetal heart rate = 120 to 160 bpm) and variability, indicating decreased oxygenation. Fetus B is in severe distress. The heart rate is low and the multiple, recurrent, late decelerations indicate decreased blood flow from the mother to the fetus.Incorrect: Fetus A has a normal heart rate, and periodic accelerations indicate fetal movement or compression of the umbilical vein during contractions. Fetus B needs careful monitoring because of the borderline heart rate and variable decelerations. Change in maternal position or increased maternal oxygenation might improve fetus B's heart rate and deceleration pattern. fetus A's baseline heart rate equal to 158 bpm with recurrent accelerations and fetus B's baseline heart rate equal to 144 bpm with short-term and long-term variability. fetus A's baseline heart rate equal to 125 bpm with occasional early decelerations and no detection of fetus B's heart rate. fetus A's baseline heart rate equal to 118 bpm with decreased short-term variability and fetus B's baseline heart rate equal to 104 bpm with multiple recurrent, late decelerations. fetus A's baseline heart rate equal to 139 bpm with periodic accelerations noted and fetus B's baseline heart rate equal to 120 bpm with variable decelerations noted. 12

A primigravida is admitted for induction of labor. The provider evaluates her and assigns her a Bishop score of 7. This means that: Correct: Bishop scores are tallied with scores between 0 and 3 assigned for cervical dilation, cervical effacement, fetal station, cervical consistency, and cervical position. A Bishop score above 6 is required to insure the likelihood of a successful labor induction. Bishop scores between 5 and 9 are associated with a 10% induction failure rate, so this client's induction has a high probability of success.Incorrect: Bishop scores range from 0 to 15, and all correlate with induction success or failure rates.Incorrect: Cesarean section must have a specific indication. Bishop scores merely predict the success of labor induction. If labor must be induced for a reason that would be an indication for cesarean delivery and the Bishop score predicts low success, then a cesarean delivery would probably be done.Incorrect: If there is a threat to maternal and/or fetal well-being and the Bishop score does not predict a successful induction, options other than waiting a week will be considered. This client's Bishop score, however, does not indicate waiting another week to induce labor in this client. the induction of labor is likely to be successful. the test is inconclusive and should be repeated. a cesarean section would be recommended. the provider should wait a week before inducing labor. 13

When planning discharge care for a client who had been admitted for preterm labor, the nurse finds that the client no longer has transportation to the clinic where she has been receiving prenatal care, is uninsured, and now lives within walking distance of the hospital's prenatal clinic. To ensure access to prenatal care for this client, the nurse: Incorrect: This will only facilitate access for one prenatal visit, not for seamless community care. Seamless care requires coordination as clients move among primary care, acute care, and community services.Correct: A major component of effective prenatal care is providing access to care. Since this client lives close enough to the hospital's clinic to walk, she will be able to continue her prenatal care, providing bed rest is not prescribed for her.Incorrect: This might not be possible for the client for the next visit, nor for all the remaining visits she will need before and after delivery. The geographic distance and lack of reliable transportation will remain a factor interfering with her access to care.Incorrect: Although this is a helpful intervention, the client needs immediate access to care, with or without medical insurance. secures a taxi voucher from the nursing supervisor to take her to her original prenatal clinic for her next scheduled visit. makes an appointment for her at the hospital's prenatal clinic, requesting that the staff obtain the client's medical records from the previous care provider. encourages the client to find a person who can drive her to her original prenatal clinic the day after discharge to continue her care. refers the client to the appropriate social services person before discharge to determine the client's eligibility for some type of medical insurance. 14

To help a new mother cope with feelings of depression, fatigue, anxiety, and sadness during the first few days postpartum, the nurse suggests that she: Correct: Many new mothers do not admit to having postpartum blues or are unaware of how common it is, so encouraging them to express their feelings might increase the possibility of treatment for those who require it. In addition, good communication with others is, in most cases, a helpful measure.Incorrect: This is unlikely to have any impact on postpartum blues, in fact, some new mothers might feel guilty for not adhering exclusively to breastfeeding or become excessively concerned about how it will affect the baby's ability to breastfeed successfully.Incorrect: This is not possible for many new mothers, so suggesting it would reinforce any unrealistic expectations the client might have about this issue.Incorrect: This is not a current recommendation for managing the mother's emotional responses during the first postpartum week. talk with her partner/support person about how she feels about her ability to care for the baby. introduce supplemental bottle feedings so that others can assist when she feels especially fatigued. plan a sleep schedule that allows long rest periods as soon as possible after hospital discharge. take vitamin C supplements along with her regular diet during the first postpartum week. 15

A client who is at 10 weeks' gestation has a rubella titer of 1:10. The nurse understands that this means that: Correct: A rubella titer of 1:10, as confirmed by a hemagglutination inhibition (HAI) test, indicates immunity to rubella.Incorrect: No matter what the client's rubella titer might be, the rubella vaccine is not given during pregnancy. This is because the vaccine is made with attenuated (live) virus, which could cross the placenta and put the fetus at risk.Incorrect: In the absence of clinical signs and symptoms of rubella, there is no reason to believe that the client is currently infected with rubella.Incorrect: All children need a combination measles, mumps, and rubella immunization between the ages of 12 and 15 months, regardless of their mother's rubella titer during pregnancy. the client has developed immunity to rubella. the client should receive a rubella immunization immediately. the client is currently infected with rubella. the client's infant will not need a rubella immunization.

A nurse is assessing a full-term male newborn's physiological adaptation. He suspects a problem with the infant's urinary function based on his finding that the: Incorrect: In general, most healthy term newborns produce between 15 to 60 mL for each kilogram of body weight during a 24-hour period. This rate would roughly equal 120 mL/24 hours, and assuming this term infant weighs between 3 and 4 kg (roughly between 6.5 and 9 pounds), this output would fall within the normal range.Incorrect: About 92% of infants void by 24 hours after birth, and 99% void by 48 hours after birth. A problem would not be suspected unless the infant has not voided by 48 hours after birth.Incorrect: Occasionally, a newborn infant's urine leaves "brick dust spots" on the diaper. These discolorations are caused by urates and they are harmless.Correct: A deflection or deviation of the urinary stream is a sign of hypospadias, a congential anomaly in which the urinary meatus is not located at the tip of the glans penis, usually on the ventral surface instead. With the infant lying supine, the urinary stream will be deflected, with the degree and angle of deflection varying with the location of the meatus. Hypospadias is usually corrected surgically and is a contraindication for circumcision. infant's average urine output is about 5 mL/hour. infant has not yet voided at 16 hours post delivery. infant's urine leaves multiple pinkish stains on the diaper. infant's urinary stream is deflected downward. 17

A gravida 1 para 0 at 28 weeks of gestation is seen at a routine prenatal clinic visit. She tells the nurse that she is worried about preterm labor because others in her family, including her two sisters, have experienced it. The nurse teaches the client about preterm labor, her risks, and what to observe for, explaining that: Incorrect: Although risk-scoring strategies have been devised to assess a woman's potential for preterm birth based on socioeconomic status and lifestyle, which might be factors shared with others in her family, these strategies have proved to be of limited value. The clearest predictors are related to a client's own personal medical and obstetric history, not to those of other family members.Correct: Initial signs of preterm labor are often subtle and some are also common with normal pregnancies. These include back pain, vaginal discharge, urinary frequency, and diarrhea. The more obvious signs are menstrual-like cramps, pelvic pressure, intestinal cramping, and vaginal bleeding. The nurse teaches her that if she experiences any of these signs at all, she should notify the provider immediately.Incorrect: Although this might be true to some extent, and the nurse certainly should explain any correlation between her family members' pregnancy experiences and her own, this client needs evidence-based information about her own risks and observations, and not casual advice.Incorrect: It is important to stay well hydrated throughout pregnancy, but considerably more fluid than that is essential for meeting this goal. Generally, an intake of 64 to 80 ounces (roughly 2 liters) of nonalcoholic and non-caffeinated beverages per day is recommended during pregnancy. At least half of this intake should be water. This remains true whether or not a woman is at increased risk for preterm labor. she is at high risk for preterm labor due to her family history. the signs of preterm labor can be extremely subtle. she needs to focus on herself and not on her family members. she should be sure to drink 4 to 6 glasses of fluid each day. 18

A nurse should consider the possibility of neonatal abstinence syndrome when a newborn: Incorrect: An infant withdrawing from narcotics or other substances abused maternally is likely to have an increased muscle tone, along with other central nervous system disturbances.Correct: Symptoms of withdrawal from maternal substance abuse include central nervous system disturbances, such as an excessive or continuous high- pitched cry and a markedly hyperactive Moro reflex.Incorrect: Most newborns sleep for varying amounts of time after feeding. Symptoms of withdrawal from maternal substance abuse include difficulty moving through various sleep stages. These infants might only sleep for very short periods of time. This sleep pattern disturbance is related to central nervous system excitation secondary to drug or alcohol withdrawal.Incorrect: Many newborns have mild tremors when they are disturbed. What distinguishes infants who have neonatal abstinence syndrome from this normal pattern is that they have moderate to severe tremors when they are undisturbed. has a decreased muscle tone. has a continuous high-pitched cry. sleeps for 2 hours after feeding. has mild tremors when disturbed. 19

During an assessment of a client who is in her first trimester of pregnancy, the nurse finds bruises and other signs of frequent and recent falls. The client denies physical abuse and also denies nausea and reports that she has been eating balanced meals and healthful snacks. Prior to her pregnancy, the client completed a treatment program for chemical dependency, and she reports that she has maintained sobriety since completing treatment. What additional laboratory test should the nurse monitor to help determine the cause of the client's falls? Incorrect: Although hypoglycemia can lead to falls, gestational diabetes usually becomes more symptomatic during the second half of pregnancy as fetal metabolic demands grow. Also, although episodic hypoglycemia can develop related to reduced or delayed food intake, this client states that she has been eating regularly and healthfully.Incorrect: Approximately 20% of women develop anemia during pregnancy, and it is usually caused by iron deficiency. However, anemia is not a likely cause of falling.Correct: Periodic drug screenings are required to evaluate a client's substance abuse and to assure continued rehabilitation.Incorrect: Very few pregnancies are complicated by hyperthyroidism, plus it would be unlikely to cause frequent falls. Symptoms of hyperthyroidism include fatigue, sweating, intolerance to heat, emotional swings, and rapid pulse with a wide pulse pressure. Blood glucose Hemoglobin Toxicology Thyroid function 20

During a nonstress test on a client who is at 32 weeks' gestation, the fetal heart rate accelerates with each episode of fetal movement. The nurse concludes that the: Incorrect: It can be difficult to obtain a suitable tracing when the fetus is asleep or the woman is receiving certain medications. Otherwise, nonstress test results are easy to interpret.Incorrect: A nonreactive test result where the fetal heart rate does not accelerate with fetal movement might indicate a fetus distressed by hypoxia, acidosis, or congenital anomalies. However, a nonreactive result does not confirm fetal compromise.Incorrect: A nonreactive nonstress test, that is, one that shows no changes at all in fetal heart activity, would warrant further testing to evaluate fetal status.Correct: Two or more accelerations of the fetal heart rate accompanying each episode of fetal movement is a reactive result. This means that, at this point, the pregnancy can safely continue because the fetus is not distressed. results cannot be interpreted. fetus is compromised. woman and fetus need further testing. pregnancy can safely continue.