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Weight gain of two pounds during a two week period at thirty four weeks gestation is considered a normal finding. Typically, a woman is expected to gain about one pound per week during the third trimester. Because this weight gain aligns with standard prenatal growth curves, it does not indicate a pathological process like preeclampsia or gestational diabetes. Therefore, the nurse would document this finding as normal and continue routine monitoring of the pregnancy.

Dependent edema of 1+ in the lower extremities is a common physiological occurrence during the third trimester of pregnancy. It results from the gravid uterus compressing the inferior vena cava, which increases hydrostatic pressure in the lower limbs. While generalized edema involving the face or hands can be a warning sign of pregnancy induced hypertension, mild pedal edema is expected. This finding does not require immediate notification of the healthcare provider unless accompanied by high blood pressure.

A fetal heart rate of 110 beats per minute is within the normal baseline range of 110 to 160 beats per minute. Fetal heart rate is a primary indicator of fetal well being and oxygenation. Since 110 represents the lower limit of normal, the nurse should continue to monitor the fetal heart rate for variability and accelerations. However, because it remains within the established safe parameters, it is not an urgent finding that necessitates reporting to the physician.

Prolonged labor lasting twenty four hours is a known risk factor for various postpartum complications, including exhaustion and increased risk of infection. While a lengthy labor increases the opportunity for bacteria to ascend into the uterine cavity, it is generally considered a secondary risk factor compared to the duration of membrane rupture. The mechanical process of labor itself does not introduce as much pathogenic risk as the loss of the protective amniotic barrier for an extended period.

Epidural anesthesia is a common pain management intervention during labor that involves the placement of a catheter in the epidural space. While any invasive procedure carries a minor risk of infection at the site of insertion, it is not a significant risk factor for the development of endometritis. Endometritis is specifically an infection of the inner lining of the uterus. Epidural use is unrelated to the inflammatory and infectious processes that occur within the uterine decidua post delivery.

A third degree perineal laceration involves the vaginal mucosa, perineal skin, and the anal sphincter muscle. While this injury significantly increases the risk for localized perineal infections or abscesses, it is not the primary cause of endometritis. Endometritis involves the upper reproductive tract, specifically the uterine lining. Although bacteria from the perineum could theoretically migrate, the proximity and direct exposure of the intrauterine environment during prolonged rupture of membranes represent a much higher risk.

While methylergonovine causes vasoconstriction, it is not specifically contraindicated for deep vein thrombosis in the same way it is for hypertension. Deep vein thrombosis involves a blood clot in the venous system, whereas the primary danger of methylergonovine relates to arterial pressure and vasospasm. While the nurse should monitor any patient with a thrombosis closely, a blood pressure reading above 140/90 mm Hg remains the absolute contraindication for the administration of this specific oxytocic medication.

A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute but is not a contraindication for methylergonovine. Slight tachypnea can be caused by pain, anxiety, or the physical exertion of the postpartum period. Methylergonovine does not typically depress or significantly alter respiratory function in a way that would require withholding the dose for a rate of 22. The primary focus for this drug is always the cardiovascular assessment.

A large amount of lochia rubra is the primary indication for administering methylergonovine maleate. This medication is specifically given to promote uterine involution and contraction to stop excessive postpartum bleeding or hemorrhage. Withholding the drug because of heavy bleeding would be counterproductive to the treatment goals. The only reason to withhold it in the presence of heavy bleeding would be if the client's blood pressure was elevated, as seen in this specific clinical scenario.

Termination of pregnancy is not indicated for a diagnosis of human papillomavirus or vaginal warts. While some strains of HPV are associated with cervical cancer, the presence of warts during pregnancy does not harm the developing fetus in a way that warrants ending the pregnancy. Treatment focuses on managing the symptoms and monitoring the mother. Suggesting termination would be medically inappropriate and provide incorrect information regarding the risks associated with this common viral infection during pregnancy.

Penicillin G is an antibiotic used to treat bacterial infections, most notably syphilis, which is caused by the spirochete Treponema pallidum. Human papillomavirus is a viral infection, and therefore, it does not respond to antibiotic therapy with penicillin. Providing penicillin G would be ineffective for treating vaginal warts and would expose the client to unnecessary medication and potential allergic reactions. The nurse must distinguish between bacterial and viral sexually transmitted infections when educating the pregnant client.

Acyclovir is an antiviral medication specifically used to treat herpes simplex virus infections by inhibiting viral DNA synthesis. It is not an effective treatment for human papillomavirus, which causes vaginal warts. Using acyclovir to treat HPV would be a pharmacological error. Treatment for HPV warts during pregnancy is often delayed until postpartum, or conservative methods like cryotherapy or specific acids are used if the warts obstruct the birth canal, but acyclovir is never used.

Nutritional requirements are important during adolescent pregnancy because the teenager is often still growing herself, creating a dual nutritional demand. While proper intake of folic acid, iron, and protein is vital for fetal development and maternal health, it is not the most critical information for safety. Teaching about nutrition helps long term outcomes, but it does not address the immediate, life threatening complications that can occur during the gestational period which require urgent medical intervention.

Education regarding pain management options during labor is a standard part of any prenatal curriculum. However, for an adolescent who may have limited knowledge of the physiological changes of pregnancy, this information is less critical than recognizing danger signs. While knowing about epidurals or breathing techniques reduces anxiety, it does not provide the client with the tools needed to identify and report complications that could jeopardize her life or the life of the unborn child.

Comparing infant feeding methods, such as breastfeeding versus formula feeding, is an essential part of preparing for parenthood and neonatal care. This information helps the adolescent make an informed choice that fits her lifestyle and school schedule. However, this education pertains to the postpartum period. In the context of a prenatal seminar, the immediate safety of the mother and the fetus during the actual pregnancy must take precedence over future nutritional choices for the infant. .

While stabilization is important, the primary medical necessity for the second hand is not merely to check if the uterus is in place. The location of the uterus is typically determined by the primary hand at the fundus relative to the umbilicus. Assessing position is a diagnostic step, whereas the use of two hands is a safety intervention. The second hand specifically protects the structural integrity of the lower segment against the downward force of the massage.

Measuring bladder height is not performed during a fundal massage using this two-handed technique. A distended bladder can displace the uterus upward and to the right, which inhibits effective uterine contraction. If the bladder is full, it is identified by palpation and the client is encouraged to void or is catheterized. The second hand during fundal massage is positioned too low at the symphysis pubis to accurately measure or assess the height of the bladder.

Fundal massage is often quite uncomfortable or even painful for the postpartum client due to the firm pressure required to stimulate uterine involution. While the nurse should explain the procedure to reduce anxiety, the technical requirement for the second hand is rooted in physiological safety rather than comfort. Using two hands does not significantly reduce the sensation of the massage; its role is strictly to prevent the serious mechanical complication of uterine inversion during the procedure.

Fetal movement, also known as quickening, is a normal and expected finding at 20 weeks gestation. Multipara clients often feel movement as early as 16 weeks, while primiparas typically feel it around 18 to 20 weeks. The presence of these movements indicates fetal viability and neurological development. Since this is a milestone that confirms a healthy progressing pregnancy, it does not require further evaluation or medical intervention as it is a reassuring clinical sign.

Leakage of clear or yellowish fluid from the breasts at 20 weeks is colostrum. This is a normal physiological occurrence as the breasts prepare for lactation under the influence of prolactin and other hormones. Colostrum is rich in antibodies and is the precursor to mature breast milk. Because this finding is expected during the second trimester, it is not a cause for clinical concern and does not warrant an extensive diagnostic workup or further medical evaluation.

Fundal height at 20 weeks gestation is expected to be approximately 20 cm, or at the level of the umbilicus. The general rule is that between 18 and 32 weeks, the fundal height in centimeters matches the weeks of gestation within a range of plus or minus 2 cm. Since the measurement of 20 cm is exactly what is predicted for this stage of pregnancy, it indicates appropriate fetal growth and amniotic fluid volume without further investigation.

Obtaining a type and crossmatch for blood products is a vital intervention for a client suspected of having abruptio placentae or severe hemorrhage. However, blood products are not immediately available as the laboratory requires time to process the match. While this task must be performed quickly, it does not take priority over the immediate restoration of circulating volume to prevent hypovolemic shock. The nurse must first establish access and initiate fluid resuscitation before blood arrives.

Inserting an indwelling urinary catheter is used to monitor renal perfusion by measuring hourly urine output. In a shock state, maintaining a urine output of at least 30 mL/hr is a goal. While this is important for ongoing monitoring of the client's hemodynamic status, it is not the highest priority. Physical stabilization of the blood pressure and heart rate through intravenous fluid replacement must occur before the nurse focuses on secondary monitoring tasks like catheterization.

Monitoring oxygen saturation is a standard part of assessing a hemodynamically unstable client. Ensuring adequate oxygenation is important because hemorrhage reduces the number of hemoglobin molecules available to transport oxygen to tissues. However, the primary issue in this scenario is the loss of volume leading to decreased cardiac output. While the pulse oximeter provides valuable data, the most critical therapeutic action is the rapid infusion of fluids to stabilize the falling blood pressure.

Orogastric tubes and syringes for gavage feedings are indicated for infants who have a weak suck or are unable to coordinate breathing and swallowing, often seen in premature neonates. While maintaining nutrition is important for an infant with hyperbilirubinemia to encourage bowel movements and bilirubin excretion, most full-term one-week-old infants can feed orally. Unless the infant is lethargic and unable to feed, these supplies are not the primary requirement for standard phototherapy treatment.

Weighing diapers and recording urinary output is necessary to monitor the hydration status of a newborn, especially since phototherapy can increase insensible water loss. However, these are standard nursing monitoring tools rather than the specific equipment needed to initiate the treatment for hyperbilirubinemia. The most essential items for the actual treatment involve the delivery of light and the protection of the infant's physiological structures from that light during the therapeutic process.

A butterfly needle and syringe for an arterial blood gas are used to assess respiratory status or acid-base balance. This is not a standard procedure for an infant admitted with hyperbilirubinemia. Bilirubin levels are monitored through total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) measurements, which involve venous or capillary blood draws or skin sensors. ABG testing is invasive and unnecessary for managing high bilirubin levels in a otherwise stable full-term infant.

Normal pregnancy physiology involves significant hormonal shifts that alter insulin requirements over time. During the first trimester, insulin needs often decrease due to increased insulin sensitivity and placental consumption of glucose. However, as pregnancy progresses into the second and third trimesters, insulin resistance increases sharply due to placental hormones like human placental lactogen. Therefore, teaching the client that injection requirements remain static is scientifically inaccurate and potentially dangerous for glycemic control.

This statement is physiologically incorrect because the pancreas actually increases insulin production in a healthy pregnancy to compensate for the insulin-resistant state created by the placenta. Gestational diabetes occurs when the maternal pancreas cannot produce enough additional insulin to overcome this resistance. The issue is not a decrease in the absolute production of insulin compared to the pre-pregnancy state, but rather a relative deficiency in meeting the vastly increased metabolic demands and resistance levels.

Monitoring requirements actually intensify during the first trimester because the risk of hypoglycemia is higher. During this period, the developing fetus utilizes maternal glucose rapidly, and hormonal changes can enhance insulin sensitivity. Frequent monitoring is essential to adjust dosages and prevent hypoglycemic episodes, which can be just as harmful as hyperglycemia. Suggesting less frequent monitoring contradicts standard obstetric guidelines for managing gestational diabetes and ensuring both maternal and fetal safety throughout the pregnancy.