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30. A woman whois 36 weeks pregnant presents to the labor and delivery unit with a history ofcongestive heart disease. Which of the following findings should the nurse report to the primaryhealth-care practitioner? a. Presence of chloasma b. Presence of severe heartburn c. 10-pound weight gain in a month d. Patellar reflexes +1ANS: ¢ Feedback a. Chloasma is a normal pregnancy finding. b. Heartburn is an expected finding during the third trimester. c. The weight gain may be due to fluid retention. Fluid retention may occur in patients with pregnancy-induced hypertension and in patients with congestive heart failure. The physician should benotified. d. Although slightly hyporeflexic, patellar reflexes of +1 are within normal limits. KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level:Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 31, Ms. M is 38 weeks gestation and is a G1 PO. At 10 pm Ms. M has just been informed by the nurse thatshe is 3 to 4 em dilated, cervix is 100% effaced, and contractions are every 4 to 5 Maternal-Newbom Nursing: The Critical Components Of Nursing Care, 3rd Edition, Roberta Durham, Linda Chapman minutes. When the nurse tells her the findings from the SVE, Ms. M states that she had been contracting since early that moming and she becomes extremely frustrated stating | should have had this baby by now. What is thebest response by the nurse? a. Remind her that length of labor for the first child can be 18 to 24 hours b. Promote relaxation techniques c. Discuss various analgesic options d. Tell Ms. M that the provider will be contacted immediately about the slow progress of laborANS: b Women in the latent phase of labor may be frustrated with lack of progress or slow progress of labor and desire companionship and encouragement. The other responses are inappropriate. The nurse should first encourage breathing and relaxation methods as well as provide reassurance, and then contact the provider. KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Analysis | Content Area: Intrapartum Care | Client Need: Health Promotion and Maintenancelntrapartum Care | Difficulty Level: Difficult 32, Ms. P has delivered her first baby 30 minutes ago and the placenta delivered 15 minutes ago. She isattempting to breastfeed her newbom daughter for the first time. Which action by the nurse would NOTbe appropriate? a. The nurse is checking the BP every 15 minutes b. The nurse is massaging the fundus vigorously c. The nurse is auscultating the infants heart and lungs while on the mothers chest d. The nurse is leaving the patient unattended for 30 minutes to bond with her newbornANS: d During the fourth stage of labor the mothers should not be left unattended as maternal bleeding needs tobe closely monitored. @ O 2