A client, now 37 weeks pregnant, calls the clinic because she's concerned aboutbeing short of breath and is unable to sleep unless she places three pillows under herhead. After listening to the client's concerns, the nurse should take which action?a. Make an appointment because the dent needs to be evaluated.
b. Explain that these are expected problems for the latter stages of pregnancy.
c. Arrange for the dent to be admitted to the birth center and prepare for birth.d. Tell
the client to go to the hospital; she may be experiencing signs of heart failure.
The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health careprovider. In this case, the client indicates normal physiologic changes caused by thegrowing uterus and pressure on the diaphragm. These signs don't indicate heartfailure. The client doesn't need to be seen or admitted to the birth center.Reference: Maternal & Child Health Nursing: Care of the Childbearing andChildrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.
During the first trimester, a nurse evaluates a pregnant client for factors that suggestshe might abuse a child. Which parental characteristic is of most concern to thenurse?a. The client didn’t graduate high school.
b. The client states she is stupid and ugly.
c. The client is carrying twins. The client eats fast food every day.
Typically, the abusive parent has low self-esteem, which may beevident by self-deprecating statements, and many unmet needs. Lack of nurturingexperience and inadequate knowledge of childhood growth and development mayalso contribute to the potential for child abuse. A low educational level, multiplegestations, and poor diet aren't direct risk factors for committing child abuse.
Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearingand Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.1743.
A client in her 15th week of pregnancy has presented with abdominal cramping andvaginal bleeding for the past 8 hours. She has passed several clots. What is theprimary nursing diagnosis for this client?a. Deficient knowledge of pregnancyb
. Deficient fluid volume
c. Anticipatory grievingd. Acute pain
If bleeding and clots are excessive, this client may becomehypovolemic , leading to a nursing diagnosis of Deficient fluid volume. AlthoughDeficient knowledge (pregnancy), Anticipatory grieving, and Acute pain areapplicable to this client, they aren't the primary diagnosis
Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearingand Childrearing Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.400.
A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To helpdetermine whether the client is at risk for a TORCH infection , the nurse shouldask:a. “Have you ever had osteomyelitis?”b. “
Do you have any cats at home?
c. “Do you have any birds at home?’d. “Have you recently had a rubeola vaccination?”
Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpessimplex virus and agents that may infect the fetus or neonate, causing numerous illeffects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting rawmeat, or through contact with raw meat followed by improper hand washing.Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted bybirds; and rubeola aren't TORCH infections
Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearingand Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.288.