NCLEX - ADULT HEALTH ANTEPARTUM - 127 To perform the Heimlich maneuver on an unconscious woman in an advanced stage of pregnancy, place

the woman on her back. Place a wedge, such as a pillow or rolled blanket, under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. Options 1, 2, and 3 are incorrect and can harm the woman and the fetus. The myometrium is the middle layer of thick muscle in the uterus. These muscles assist the birth process by expelling the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os. Options 1, 3, and 4 describe the other layers of the uterus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus. By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Option 2 occurs at the end of the ninth week. Option 3 occurs at the end of the thirty-eighth week. Option 4 occurs at the end of the seventh week. The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/min in the first trimester but slows with fetal growth to 120 to 160 beats/min near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 beats/min with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the physician. Options 3 and
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4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the physician needs to be notified. The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations from the 28-day cycle may be associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the woman's cycle. The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and folliclestimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tubes for 3 days. FSH and LH, when stimulated by gonadotropin-releasing hormone (GnRH) from the hypothalamus, are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the graafian follicle, and production of progesterone. Options 1, 3, and 4 are incorrect. A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would not be favorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. The platypelloid pelvis (flat pelvis)
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has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate. The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta. The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, maintains the body temperature of the fetus, and helps measure kidney function, because the amount of fluid is based on the amount of urination from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus. Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Options 1, 2, and 3 are incorrect. Quickening is fetal movement and may occur as early as the sixteenth to twentieth week of gestation. The expectant mother first notices subtle fetal movements during this time, which gradually increase in intensity. Options 1, 2, and 3 are incorrect. The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/min in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 120 to 160 beats/min.

Options 1, 2, and 3 are normal expected findings. For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy, and it should be used only when a life-threatening infection is present. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients should continue to abstain until they become culturenegative, because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry will promote healing. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus' age in weeks 2 cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus, and at 36 weeks the fundus is at the xiphoid process. Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies. T is term births, the number born at term (longer than 37 weeks), P is preterm births, the number born before 37 weeks' gestation, A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks' gestation; included in parity if past 20 weeks' gestation), and L is the number of current living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1 and the number of preterm births is 0. The number of abortions is 0 and the number of living children is 1.
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Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions. In the early weeks of pregnancy, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening is noted by the examiner during pelvic examination. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta. Human chorionic gonadotropin is noted in maternal urine in a positive urine pregnancy test. Goodell's sign does not indicate the presence of fetal movement. Accurate use of Ngele's rule requires that the woman have a regular 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period, subtract 3 months, and then add 1 year to that date. First day of the last menstrual period, October 19, 2008; add 7 days, October 26, 2008; subtract 3 months, July 26, 2008; add 1 year, July 26, 2009. The probable signs of pregnancy include uterine enlargement, Hegar's sign (softening and thinning of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 6), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin (hCG). Positive signs of pregnancy include fetal heart
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rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by a nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography. By the twentieth week of gestation, the fundal height should be at the umbilicus. Option 2 identifies the height of the uterus at 16 weeks of gestation. Option 3 identifies the height of the uterus at 12 weeks' gestation. Option 4 identifies the symphysis pubis area, prepregnancy location. 3Dietary sources of iron include lean meats, liver, shellfish, dark green leafy vegetables, legumes, whole grains, and enriched grains, cereals, and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C. Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs will increase the blood flow to the area and worsen the discomfort from hemorrhoids. The pregnant client should be instructed to wash the breasts with warm water and keep them dry. The client should be instructed to avoid using soap on the nipples and areola area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses will cause discomfort. The client is instructed to wear softtextured clothing to decrease nipple tenderness and to use breast pads inside
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the bra to prevent leakage if colostrum is a problem. The nonstress test takes about 20 to 30 minutes. The test is termed nonstress because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions (medication is not given) to obtain the necessary data. The test is noninvasive (an informed consent is not required), and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen, where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement also is secured to the maternal abdomen. Fetal heart activity and movements are recorded. Between 14 and 20 weeks' gestation, the pulse increases about 10 to 15 beats/min, which then persists to term. Options 2, 3, and 4 are incorrect. During pregnancy, the blood pressure usually remains the same as the prepregnancy level, but then gradually decreases up to about 20 weeks of gestation. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus. During pregnancy, there is an accelerated production of RBCs. A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 beats/min) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 beats/min must occur, each with a duration of at least 15 seconds, in a 20-minute interval. Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations
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occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period. Therefore, options 2, 3, and 4 are incorrect interpretations. Leafy green vegetables are rich in folate (folic acid). Bananas provide potassium; milk and yogurt supply calcium. . Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin level. The laboratory values in options 1, 2, and 4 are within normal limits for the pregnant client. Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing such as knee-high hose impede venous return from the lower legs and thus place the client at higher risk for developing varicosities. Clients should be encouraged to wear panty hose or support hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and minimize the risk for falls. Pants with an elastic waistband are comfortable and are not constricting. The nurse should instruct the client to drink 6 glasses of water per day and to consume a diet that includes roughage to prevent the constipation. The client should not take stool softeners, laxatives, mineral oil, other medications, or enemas without first consulting with the physician or nurse-midwife. Some measures that will assist in relieving a backache include maintaining good posture and body mechanics, resting and avoiding fatigue, wearing flatheeled shoes, and sleeping on a firm mattress. The back discomfort that occurs in a pregnant client is often caused by the exaggerated lumbar and cervicothoracic curves resulting from a change in the
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center of gravity because of the enlarged uterus. Performing more exercises to strengthen the back muscles could be harmful to a pregnant client. Because amniocentesis is an invasive procedure, informed consent will need to be obtained before the procedure. After the procedure, the client is instructed to rest but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications such as vaginal discharge, severe, persistent cramping, or onset of fever. Amniocentesis is an outpatient procedure and may be done in a physician's private office or in a special prenatal testing unit. Hospitalization is not necessary following the procedure. Leukorrhea begins during the first trimester. Many clients notice a thin colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or the emergency room immediately. If vaginal discharge is profuse, the client may use panty liners but should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently. Nonweight-bearing exercises are preferable to weight-bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non weight-bearing exercises such as swimming are allowable. Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac,
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embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 3 identify components of the abdominal ultrasound. Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and minimize falls. Leg cramps occur when the pregnant client stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Options 1, 3, and 4 are not measures that will provide relief from the leg cramps. Lying down is likely to lead to reflux of stomach contents, especially immediately following a meal. The client should be instructed to avoid spices, along with salt, because spices will trigger heartburn. Salt will produce edema. The client should be encouraged to eat between-meal snacks and should be instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating three large meals. The client also should limit or avoid gas-producing and fatty foods. The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this
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procedure, can cause discomfort, and presents a risk of vena cava (hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the physician or nurse-midwife if there are fewer than 10 kicks in a 12-hour period or as instructed by the physician or nurse-midwife. More than one medication may be used to prevent the growth of resistant organisms in the pregnant client with tuberculosis. Treatment must continue for a prolonged period of time. The preferred treatment for the pregnant client is isoniazid (INH) plus rifampin (Rifadin) daily for a total of 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (Vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. It is not necessary for the client to stay at home during treatment and therapeutic abortion is not required. The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. An increase of 600 additional calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs increase. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not
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required. Stress causes increased heart workload, and the client should be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting should be done by lying on the side to promote blood return. Constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. Therefore, high-fiber foods are important. A lowcalorie diet is not recommended during pregnancy and could be harmful to the fetus. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients, so adequate fluid intake and high-fiber foods are important. Sodium should be restricted somewhat, as prescribed by the physician, because excess sodium will cause an overload to the circulating blood volume and contribute to cardiac complications. Human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passing from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases, a history of multiple sexual partners, or have used intravenous drugs. A heterosexual partner, particularly a partner who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV. A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The use of resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. These resources are not intended to minimize potential risk of
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maternal infection or prepare the client and family for the subsequent labor, delivery, and hospitalization. If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal signs. Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, then it will be performed at the clinic or health care provider's office. Signs of infection need to be reported to the health care provider. Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy. Strict bed rest throughout the remainder of the pregnancy is not required. The client is advised to curtail sexual activities until bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the physician or other health care provider. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client also should watch for the evidence of the passage of tissue. Insulin needs decrease in the first trimester because of increased insulin production by the pancreas and increased
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peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy. The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors. Several factors are associated with preterm labor. These include a history of medical conditions, present and past obstetric problems, social and environmental factors, and demographic factors such as race and age. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus, anemia, which decreases oxygen supply to the uterus, and age younger 18 years or first pregnancy older than the age of 40. In option 1, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. Because the question identifies an adolescent who has not sought early prenatal care, she is at higher risk for the development of gestational hypertension. Options 2, 3, and 4 also deal with body image and, although these comments should not be ignored, the need for follow-up is not urgent.
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Treatment for gonorrhea consists of antibiotic therapy with ceftriaxone, plus oral doxycycline, for 7 days; therefore, option 1 is correct. Option 2 is the treatment for syphilis, option 3 is the treatment for genital herpes simplex virus, and option 4 is the treatment for chlamydia. For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to lifethreatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the placenta. Options 1, 2, and 3 may also be appropriate nursing diagnoses for the client with sickle cell anemia but are not the priority. Iron is needed both to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal RBC mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Meats are an excellent source of iron. Iron supplements usually cause constipation. Iron is best absorbed if taken on an empty stomach. Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies. Rubella titer determination is a standard antenatal test for childbearing women during their initial screening and entry into the health care delivery system. Option 4 helps clarify maternal concerns with accurate information based on the acquisition of rubella infection and potential fetal side effects.
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With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but potentially exposed newborn infants should be cultured on the day of delivery. During pregnancy, the breasts change in size and appearance. The increase in size is because of the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin. Options 2, 3, and 4 are incorrect. Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body, even when one group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body. Touch relaxation helps the woman learn to loosen taut muscles when she is touched by her partner. Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Cracked wheat bread may abrade the tender gums; drinking water with meals has no direct effect on gums, and eating saltine crackers before arising helps decrease nausea. Stress causes increased heart workload and the client should be instructed to avoid stress. To avoid infections, individuals with active infections should
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not be allowed to visit the client. Otherwise, restrictions are not required. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return. The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish 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. A contraction stress test assesses placental oxygenation and function, determines fetal ability to tolerate labor, determines fetal well-being, and is performed if the nonstress test is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation until three palpable contractions of 40 seconds or longer in a 10-minute period have occurred. Frequent maternal blood pressure readings are done and the client is monitored closely while increasing doses of oxytocin are given. Options 1, 2, and 4 are inaccurate. Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds duration in a 10-minute period. Repetitive late decelerations render the test results positive.
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The mature ovum is transported through the fallopian tube by the muscular action of the tube and the movement of the cilia within the tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovaries. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovum. Options 1, 2, and 4 are incorrect. A maternal glucose level is determined to screen for gestational diabetes. A 50-g oral glucose load may be prescribed and is followed by a serum glucose determination 1 hour later. If the test is given without regard for fasting, 140 mg/dL is the upper limit of normal. If the test is given when the woman is fasting, the upper acceptable limit is 135 mg/dL. Clients exceeding these limits should be further evaluated with a 3-hour glucose tolerance test (GTT). Options 1, 2, and 4 would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented. Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the enzyme-linked immunosorbent assay (ELISA). Options 1 and 4 are incorrect because HIV infection primarily occurs through the exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk for developing the virus. Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation. Options 2, 3, and 4 are incorrect. The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms
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may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. Options 1, 2, and 4 do represent possible outcomes of this nursing intervention, but are not the priority of care when promoting maternalfetal well-being. The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin level, and iron stores. Options 1 and 3 provide false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother. At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks' gestation, the fundus reaches midway between the symphysis pubis and umbilicus. At 20 weeks' gestation, the fundus is located at the umbilicus. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process. The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned purposeful communication that focuses on specific content. Options 2, 3, and 4 are incorrect and would not lend themselves to eliciting accurate information from the client. Visual disturbances, rapid weight gain, and generalized or facial edema are
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warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection. The normal temperature during pregnancy is 36.2 to 37.6 C (98 to 99.6 F). A temperature above this level may suggest infection that might require medical management. Options 2, 3, and 4 are unnecessary. The ovarian cycle consists of three phases, the follicular, ovulatory, and luteal phases. The proliferative phase is a phase of the endometrial cycle. The biophysical profile assesses five parameters of fetal activity: fetal heart rate (FHR), fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points, with a score of 8 being considered normal and a score of 10 perfect. Results are available immediately. Options 1, 3, and 4 are incorrect. Pregnant adolescents are at higher risk for complications. Peer pressure is an important influence on nutritional status. Adolescents often are concerned about their body image. If weight is a major focus for the adolescent, the adolescent is more likely to restrict calories to avoid weight gain. Option 1 is the only option that suggests a possible psychosocial problem. Options 2, 3, and 4 relate to physiological issues.

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Telling an adolescent to avoid fast food restaurants and to eliminate snacks may cause the adolescent to rebel. Advising an adolescent to eat only when hungry could lead to a deficit in nutrients. The nurse should appropriately teach the adolescent about appropriate weight patterns and how to monitor these patterns. The adolescent is more likely to follow suggestions and adhere to the appropriate dietary patterns if the nurse explains why the weight gain is important for the fetus as well as the mother. In order to determine each client's nutritional status and needs, the first priority of the nurse is to identify each client's food preferences. Cultural background and knowledge about nutrition are important factors influencing food choices and nutritional status. Although options 1, 2, and 3 may be a component of the sessions, option 4 is the first priority. The best source of calcium is dairy products. Women with lactose intolerance need other sources of calcium. Calcium is present in dark, green, leafy vegetables, broccoli, legumes, nuts, and dried fruits. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. Additionally, creamed spinach may not be tolerated by a client with a lactose intolerance. Orange juice does not contain significant amounts of calcium unless fortified with calcium. Cheese is a dairy product and is not tolerated by the client with a lactose intolerance. Foods containing ascorbic acid will increase the absorption of iron. Calcium and phosphorus in milk and tannin in tea decreases iron absorption. Coffee binds iron and prevents it from being fully absorbed. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements.
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An inevitable abortion is a termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion. An incomplete abortion manifests with heavy bleeding, severe cramping, cervical dilation, and passage of large clots. A threatened abortion manifests with slight to moderate bleeding and intermittent cramping without dilation. A septic abortion manifests with bleeding with odor, cervical dilation, and fever. Cramping may or may not be present. Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion although the presence of active lesions at the time of birth presents concerns. Maternal age over 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations. 3Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Weight and edema are priority interventions for the client with preeclampsia, and an elevated temperature is an indicator of infection. An abnormal pregnancy (ectopic) is suspected if -hCG is present but at lower levels than expected. The absence of hCG would indicate no pregnancy, whereas normal limits could indicate a normal pregnancy. High levels could indicate a molar pregnancy. Known risk factors that increase the risk of developing gestational diabetes include obesity (over 198 pounds), chronic hypertension, family history of diabetes mellitus, previous birth of a
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large infant (over 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes. Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric intake is not affected by diabetes. The most common signs and symptoms of gestational trophoblastic disease (hydatidiform mole) include elevated levels of hCG, vaginal bleeding, largerthan-normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of gestational hypertension. Fetal activity would not be noted. Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken, rice, and cheese are not high in folic acid. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein. Pork is a good source of thiamine. hCG can be detected in the blood as early as 6 days after conception or 20 days after the last menstrual period. Options 1, 2, and 3 are unrelated to determining the presence of a pregnant state. Ngele's rule is a noninvasive method for estimating the date of birth. The rule states the following: add 7 days to the first day of the last menstrual period, subtract 3 months, and add 1 year. This is based on the assumption that the cycle is 28 days. March 7, 2008, plus 7 days minus 3 months is December 14, 2007.
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Adding 1 year brings the delivery date to December 14, 2008. Between 14 and 20 weeks of gestation, the maternal pulse rate increases slowly, up to 10 to 15 beats/min, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy. Ngele's rule is a noninvasive method for estimating the date of birth. The rule states the following: add 7 days to the first day of the last menstrual period, subtract 3 months, and add 1 year. This is based on the assumption that the cycle is 28 days. June 17, 2008, plus 7 days minus 3 months is March 24, 2008. Adding 1 year brings the delivery date to March 24, 2009. Some strategies for decreasing morning nausea are keeping crackers, melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats; and consuming adequate fluid between meals but not with meals. A high-carbohydrate diet could increase the episodes of nausea. The client should avoid exposure to infection and not allow those persons with active infections to visit. Stress causes increased heart workload, with the potential for adverse consequences. Too much weight gain causes an increase in body requirements and increases stress on the heart. The client should rest on the left side to promote blood return. A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. Bedrest with bathroom privileges is prescribed; complete bedrest is not necessary. Urine
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should be checked for protein. A maternal blood glucose would not provide specific data related to preeclampsia. Sodium restriction is not necessary. The client with severe preeclampsia is kept on complete bedrest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a convulsion should be kept to a minimum. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs. Food and fluid are not restricted unless specifically prescribed by the care provider. A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A semi-private room with a client who enjoys watching television will provide external stimuli, which must be kept minimal for the client with severe preeclampsia. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A private room two doors away from the nurses' station is the best room assignment for this client. In vitro fertilization is a method of medically assisted reproduction for women with nonpatent, diseased, or missing fallopian tubes or with infertility of unknown etiology. Ova and sperm are obtained from the potential parent or donor, placed in a nutrient medium, and allowed to incubate, and then the fertilized ovum is transferred into the woman's uterus. The woman houses the pregnancy throughout gestation and gives birth. Option 4 describes the procedure for artificial insemination. Options 1, 2, and 3 are correct statements regarding this procedure. A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis.

An anthropoid pelvis has an oval shape, and an android pelvis is heart shaped. Teens experience a major growth spurt, and the pregnancy adds to these normal needs. Although all options may have an impact on nutritional deficiencies, the primary reason why the pregnant adolescent is at risk for nutritional deficiencies is the growth spurt. In vitro fertilization is a method of medically assisted reproduction for women with nonpatent, diseased, or missing fallopian tubes, or with infertility of unknown etiology. Ova and sperm are obtained from potential parents or donors, placed in a nutrient medium, and allowed to incubate, and then the fertilized ovum is transferred into the woman's uterus. The woman houses the pregnancy throughout gestation and gives birth. Option 4 describes the procedure for artificial insemination. Options 1 and 3 are incorrect statements regarding this procedure. A gynecoid pelvis is a normal female pelvis. A platypelloid pelvis has a flat shape. An anthropoid pelvis has an oval shape, and an android pelvis is heartshaped. Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four servings of folic acidrich foods per day. Food items high in folic acid include gland meats, yeast, dark green leafy vegetables, legumes, and whole grains. Bananas provide potassium; milk products and cheese supply calcium. Potatoes provide vitamin B6. Clinical manifestations of a Candida infection include pain, itching, and a thick, white vaginal discharge. Proteinuria, hematuria, edema, hypertension, and costovertebral angle

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pain are clinical manifestations associated with urinary tract infections. Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. To calculate the estimated date of confinement, the nurse would add 7 days to the first day of the LMP, subtract 3 months, and then add 1 year. First day of last menstrual period: February 9, 2009; add 7 days: February 16, 2009; subtract 3 months: November 16, 2009; and add 1 year: November 16, 2009. Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the left buttock during fundal height measurement will correct or prevent the problem. Options 1, 3, and 4 are unrelated to this syndrome. Condoms should be used to minimize the spread of genital tract infections. Wearing tight clothing can irritate the genital area and does not allow for air circulation. Douching is to be avoided. Wearing items with a cotton panel liner allows for air movement in and around the genital area. All pregnant women should be screened for prior rubella exposure during pregnancy. All children of pregnant women should receive their immunizations according to schedule. Additionally, no definitive evidence suggests that the rubella vaccine virus is transmitted from person to person. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to the rubivirus. Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. After birth they usually fade, although they never
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disappear completely. Options 1, 2, and 3 are incorrect. An epulis is a red, raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and forehead and is especially noticed in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasias, or vascular "spiders," are tiny, star-shaped or branch-shaped, slightly raised and pulsating endarterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. The "spiders" usually disappear after birth. The nurse should instruct the client to have an adequate fluid intake daily to assist in digestion and in the management of constipation. The pregnant client should consume at least 8 to 10 (8-oz) glasses of fluid each day, of which at least 6 glasses should be water. Because of their sodium content, diet soft drinks should be consumed in moderation. Caffeinated beverages have a diuretic effect, which may be counterproductive to increasing fluid intake. It is not necessary for the client to drink 12 glasses of fruit juices and milk every day. All pregnant clients should be advised to do the following to prevent the development of toxoplasmosis: Clients should be instructed to cook meats thoroughly, particularly pork, beef, and lamb; avoid touching mucous membranes of the mouth or eyes while handling raw meat; thoroughly wash all kitchen surfaces that come in contact with uncooked meat; wash the hands thoroughly after handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption; and avoid contact with materials that possibly are contaminated
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with cat feces, such as cat litter boxes, sand boxes, or garden soil. Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of preeclampsia. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths/min, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus. At gestational week 36, the fetus weighs 2500 g and is approximately 42 to 48 cm in length. The skin is pink and the body is rounded. Lanugo is disappearing, and the L/S ratio is greater than 2:1. At gestational week 8, the eyelids begin to fuse. The fetal heart begins to beat at week 5. The fetal skin is transparent at week 16. At 28 weeks of gestation, the fetus weighs approximately 1200 g. By gestational week 5, double heart chambers are visible by ultrasound and the heart begins to beat. The fetal heart is only two parallel tubes at week 3. At week 5, the heart can be visualized only by ultrasound. To be heard by Doppler, the gestation must be 12 weeks; to be heard by fetoscope, the gestation must be at 20 weeks.
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The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/min in the first trimester but slows with fetal growth to approximately 120 to 160 beats/min near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 beats/min with the uterus at rest, the fetus may be in distress. Options 1 and 2 indicate bradycardia. Option 4 indicates tachycardia. With mild cases of preeclampsia, the condition is monitored with self-care and bedrest while at home. The nurse must assess blood pressure, weight, and the presence of edema because an increase in these areas would indicate a worsening condition. Before the need for hospitalization is discussed, the client would need to be assessed for the progression of the disease process. The fundus can be palpated above the symphysis pubis between 12 and 14 weeks' gestation. At 20 weeks' gestation, the fundus can be palpated at the umbilicus. At approximately 28 weeks' gestation, the fundus can be palpated midway between the umbilicus and the xiphoid process. At 36 weeks, the fundus can be palpated at the level of the xiphoid process. Nausea and vomiting during the first trimester constitute a common complaint. A possible cause is the increasing levels of human chorionic gonadotropin or altered carbohydrate metabolism. The client should be instructed to avoid fried foods and to eat 5 or 6 small meals throughout the day rather than fewer larger meals. The nausea and vomiting should lessen throughout the day, but if they continue, the clinic should be notified for further intervention. Dry crackers should be eaten before getting out of bed, rather than after arising.

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Quickening is fetal movement and may occur as early as the fourteenth to sixteenth week of gestation; the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, and this is known as uterine souffle. This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar's sign. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

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