Test Bank For Maternal-Child Nursing Latest Edition
During vital sign assessment of a pregnant patient in her third trimester, the patient
... [Show More] complains of feeling faint, dizzy, and agitated. Which nursing intervention is most appropriate?
A: have the patient stand up and retake her blood pressure
B: have the patient sit down and hold her arm in a dependent position
C: have the patient turn to her left side and recheck her blood pressure in 5 minutes
D: have the patient lie supine for 5 minutes and recheck her blood pressure on both
arms - C: have the patient turn to her left side and recheck her blood pressure in 5 minutes
Blood pressure is affected by positioning during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension.
While providing education to a primiparous patient regarding the normal changes of pregnancy, what is an important information for the nurse to share regarding Braxton Hicks contractions?
A: these contractions may indicate preterm labor
B: these are contractions that never cause any discomfort
C: Braxton hicks contractions only start during the third trimester
D: these occur throughout pregnancy, but you may not feel them until the 3rd trimester - D: these occur throughout pregnancy, but you may not feel them until the 3rd trimester
Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy.
Which finding is a positive sign of pregnancy?
A: amenorrhea
B: breast changes
C: fetal movement felt by the woman
D: visualization of fetus by ultrasound - D: visualization of fetus by ultrasound
The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy.
A patient in her first trimester complains of nausea and vomiting. The patient asks, "Why is this happening?" What is the nurse's best response?
A: "It is due to an increase in gastric motility."
B: "It may be due to changes in hormones."
C: "It is related to an increase in glucose levels."
D: "It is caused by a decrease in gastric secretions." - B: "It may be due to changes in hormones."
Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause of nausea and vomiting.
The patient has just learned that she is pregnant and overhears the gynecologist saying that she has a positive Chadwick's sign. When the patient asks the nurse what this means, how would the nurse respond?
A: "Chadwick's sign signifies an increased risk of blood clots in pregnant women because of a congestion of blood."
B: "That sign means the cervix has softened as the result of tissue changes that naturally occur with pregnancy."
C: "This means that a mucus plug has formed in the cervical canal to help protect you from uterine infection."
D: "This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix." - D: "This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix."
Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Although Chadwick's sign occurs with hyperemia (congestion with blood), the sign does notsignify an increased risk of blood clots. The softening of the cervix is called Goodell's sign, not Chadwick's sign. Although the formation of a mucus plug protects from infection, it is not called Chadwick's sign.
An expected change during pregnancy is a darkly pigmented vertical mid abdominal line. The nurse recognizes this alterations as:
A: epulis
B: linea nigra
C: melasma
D: striae gravidarum - B: linea nigra [Show Less]