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A pregnant client at 28 weeks gestation is observed walking with a waddling gait. The nurse explains that this change in walking is a normal part of pregnancy. Which of the following factors is most likely contributing to the client's waddling gait?
C. Relaxation of pelvic ligaments and joints
During pregnancy, especially in the second and third trimesters, the body releases the hormone relaxin, which softens and relaxes the ligaments and joints in the pelvis to prepare for childbirth. This pelvic laxity, combined with the shifting center of gravity due to the growing uterus, contributes to the characteristic waddling gait often observed in pregnant women around 28 weeks and beyond.
A. Development of scoliosis in the spine
Scoliosis is a spinal deformity characterized by lateral curvature. While back discomfort and changes in posture are common in pregnancy, scoliosis does not typically develop suddenly during pregnancy and is not a usual cause of waddling gait.
B. Increased blood volume leading to leg swelling
Pregnancy does involve increased blood volume and may result in dependent edema, especially in the legs and feet. However, swelling alone does not cause a waddling gait. The waddling is due more to structural and hormonal changes in the pelvis and joints.
D. Increased muscle strength in the lower extremities
Pregnancy does not inherently increase muscle strength; in fact, fatigue and strain on muscles may occur. Even if strength increased, it would not cause a waddling gait—this gait results from joint laxity and altered biomechanics, not increased muscle function.
The waddling gait seen at 28 weeks gestation is a normal adaptation to pregnancy, primarily caused by the relaxation of pelvic ligaments and joints (Choice C), influenced by hormonal changes like increased relaxin levels.
A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes a pregnancy terminated by elective abortion at 9 weeks: and a pregnancy that resulted in the birth of a singleton at 39 weeks, currently alive and well . According to the GTPAL system, which of the following describes the client's current status?
Correct answer:
D. G3 T1 P0 A1 L1
Here's the explanation:
A. G3 T0 P2 A1 L1
B. G2 T1 P0 A1 L2
C. G3 T1 P0 A1 L2
D. G3 T1 P0 A1 L1 is the correct answer. The client has had 3 pregnancies, 1 full-term birth, 1 abortion, and 1 living child.
A nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations?
The correct answer is:
D. Persistent vomiting that prevents fluid intake
Explanation for the correct answer:
Persistent vomiting that prevents fluid intake is a serious concern and could indicate hyperemesis gravidarum, which requires medical intervention. The other symptoms listed, while uncomfortable, are typically normal in the first trimester and do not warrant immediate concern.
A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select All that Apply.)
Explanation for the Correct Answers:
A. Provide a dark, quiet environment
Clients with severe gestational hypertension or severe preeclampsia may be at risk for seizures, so a dark, quiet environment helps to reduce stimuli and decrease the risk of neurologic irritability and seizures.
C. Administer magnesium sulfate IV
Magnesium sulfate is given to clients with severe gestational hypertension to prevent seizures. It helps to manage neurologic irritability and can be lifesaving for seizure prophylaxis.
D. Ensure that calcium gluconate is readily available
Calcium gluconate is the antidote for magnesium sulfate toxicity, which can cause respiratory depression and cardiac issues. It is critical to have it readily available in case of an overdose.
B. Assess respiratory status every 4 hr
Respiratory status should be assessed more frequently (typically every 1–2 hours) when the client is on magnesium sulfate, as magnesium sulfate toxicity can lead to respiratory depression. Every 4 hours is insufficient.
E. Evaluate neurologic status every 8 hr
Neurologic status should be evaluated more frequently (typically every hour or every 2 hours) for early signs of eclampsia or magnesium sulfate toxicity, not just every 8 hours.
The correct answers are A. Provide a dark, quiet environment, C. Administer magnesium sulfate IV, and D. Ensure that calcium gluconate is readily available. These actions help manage severe gestational hypertension and prevent seizures. Frequent assessment of respiratory and neurologic status is necessary, so every 4 hours or every 8 hours is not adequate.
A nurse is educating a newly pregnant client about the stages of pregnancy. The client asks, "Which weeks are included in the first trimester?" The nurse correctly responds with which of the following?
The correct answer is:
B. Weeks 1-12
Explanation for the correct answer:
The first trimester is from weeks 1 to 12 of pregnancy, during which crucial development of the fetus occurs.
A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?
C. "I should increase my calcium intake to 1,500 milligrams per day."
The recommended daily intake of calcium during pregnancy is typically 1,000 milligrams for women aged 19-50. For women under 19 years old, the recommendation increases to 1,300 milligrams per day. 1,500 milligrams per day is above the usual recommended amount and would require clarification. The nurse should educate the client that calcium intake should align with the standard recommendations to avoid potential overconsumption.
A. "I should drink about 2 liters of fluid each day."
Adequate hydration is essential during pregnancy, and drinking about 2 liters (or 8 cups) of fluid daily is generally a good guideline. Pregnant women need extra fluids due to the increased blood volume and other physiological changes. This statement does not require clarification.
B. "I should not drink alcoholic beverages during my pregnancy."
This statement is correct. Alcohol consumption during pregnancy can cause fetal alcohol spectrum disorders (FASDs), which can lead to long-term physical, behavioral, and intellectual disabilities in the child. It is strongly advised to avoid alcohol during pregnancy.
D. "I can have a moderate amount of caffeine daily."
This statement is also correct. Moderate caffeine intake (up to 200 milligrams per day) during pregnancy is generally considered safe. This amount is equivalent to about one 12-ounce cup of coffee. Higher levels of caffeine can increase the risk of miscarriage, low birth weight, and preterm birth, so it's important to keep intake within the recommended limits.
The correct answer is C. "I should increase my calcium intake to 1,500 milligrams per day." The client’s statement about calcium intake exceeds the typical recommendation. The other statements are consistent with standard prenatal advice regarding hydration, alcohol consumption, and caffeine intake.
A nurse is assessing a pregnant client diagnosed with HELLP syndrome. Which of the following findings is most concerning?
C. Right upper quadrant pain
Right upper quadrant pain is a classic and most concerning sign of HELLP syndrome. This pain often results from liver distension due to hepatic involvement in HELLP syndrome, which can lead to liver rupture or hematoma formation, both of which are life-threatening complications for the mother. Prompt assessment and intervention are necessary when this symptom is present.
A. Blood pressure of 140/90 mmHg
While hypertension is a concern in pre-eclampsia and HELLP syndrome, a blood pressure of 140/90 mmHg is considered mildly elevated and is not as immediately concerning as right upper quadrant pain, which suggests hepatic involvement. However, hypertension should still be closely monitored.
B. Platelets 250,000/mm3
A platelet count of 250,000/mm3 is within the normal range (150,000–450,000/mm3). Thrombocytopenia (low platelets) is a hallmark of HELLP syndrome, but a count of 250,000/mm3 does not indicate a problem in this case.
D. Fetus expected weight for gestation
Although growth restriction is a concern in HELLP syndrome due to placental insufficiency, it is not the most immediate or concerning finding compared to right upper quadrant pain, which could indicate liver complications.
The most concerning finding in this scenario is C. Right upper quadrant pain, as it is a sign of liver involvement in HELLP syndrome, which can lead to liver rupture or other severe complications. The other findings, while important, are not as immediately concerning in this context.
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?
D. Changes in the cervix
One of the key signs of true labor is cervical changes. In true labor, the cervix begins to efface (thin out) and dilate (open) in preparation for delivery. These changes are monitored by a healthcare provider during a vaginal exam and indicate that labor is progressing. In contrast, false labor (Braxton Hicks contractions) may cause irregular contractions, but they do not result in cervical changes.
A. Station of the presenting part
The station of the presenting part refers to the position of the fetus in the birth canal in relation to the ischial spines. While it is important in assessing labor progression, station alone does not confirm whether the client is in true labor. It is more of an indicator of the fetal descent during labor.
B. Pattern of contractions
Although contractions in true labor are typically regular and increase in intensity and frequency, the pattern of contractions alone is not a definitive sign of true labor. It is the cervical changes that provide the most reliable evidence of labor progression.
C. Rupture of the membranes
Rupture of membranes (also known as the water breaking) is a sign that labor may be imminent, but it does not necessarily confirm that a woman is in true labor. Some women may have ruptured membranes without contractions, and labor may not follow immediately. Additionally, rupture of membranes can occur in both true and false labor.
The correct answer is D. Changes in the cervix. Cervical changes (effacement and dilation) are the most reliable sign of true labor, indicating that labor is progressing. The other options may be associated with labor but are not definitive signs of true labor on their own.
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?
Explanation for the Correct Answer:
D. Intrauterine growth restriction (IUGR)
Smoking during pregnancy is strongly associated with intrauterine growth restriction (IUGR), where the fetus does not grow at a normal rate in the uterus. The toxins in cigarette smoke can reduce the oxygen and nutrients that reach the fetus, which can impair fetal growth and development. This can lead to low birth weight and other complications, such as preterm birth and placental issues.
A. Congenital heart defects
While smoking during pregnancy may increase the risk for various birth defects, including congenital heart defects, it is not the primary complication associated with smoking. The risk for IUGR is more directly linked to smoking than the risk for heart defects.
B. Hearing loss
Smoking during pregnancy is not directly linked to an increased risk of hearing loss in the newborn. Hearing loss can result from various factors, but smoking is not a primary risk factor for this condition.
C. Type 1 diabetes mellitus
Type 1 diabetes is an autoimmune condition that typically develops in childhood and is not directly related to maternal smoking during pregnancy. Smoking does not increase the risk of Type 1 diabetes in the newborn.
The correct answer is D. Intrauterine growth restriction (IUGR). Smoking during pregnancy is most commonly associated with IUGR, as it restricts oxygen and nutrient supply to the fetus, leading to impaired growth. The other complications listed are not primarily associated with smoking during pregnancy.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Explanation for the correct answer:
The first priority when a prolapsed umbilical cord is observed is to relieve pressure on the cord to preserve fetal oxygenation. Inserting a gloved hand into the vagina and gently lifting the presenting fetal part off the cord helps restore and maintain blood flow through the umbilical vessels, preventing fetal hypoxia and death. This is the immediate, life-saving action the nurse must perform before any other interventions.
A. Place the client in knee-chest position
This is a secondary action that helps reduce pressure on the cord by using gravity to shift the fetus upward. However, it does not directly and immediately relieve compression of the cord like manual elevation does. Therefore, it should be done after inserting a gloved hand to relieve pressure.
B. Prepare the client for an immediate birth
Although an emergency cesarean section is likely necessary, preparing the client comes after immediate life-saving measures are taken. The fetus must first be protected from hypoxia by relieving pressure on the cord.
C. Cover the cord with a sterile, moist saline dressing
This action helps maintain cord viability and prevent drying if the cord is protruding outside the vaginal canal, but it does not address the life-threatening compression. It is important but not the first priority.
The correct answer is D. Insert a gloved hand into the vagina to relieve pressure on the cord. This is the first and most critical intervention to prevent fetal hypoxia in a prolapsed umbilical cord. While other actions such as repositioning, covering the cord, and preparing for birth are important, they should follow the immediate manual relief of cord compression.
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