Health Promotion and Maintenance
47. A client, who is gravida 6, para 2, is admitted to labor and delivery in early labor on October 18. A nurse palpates regular uterine contractions every 5 minutes with moderate intensity. A sterile vaginal examination reveals a soft cervix that is 2 cm dilated, 85% effaced, and a –2 station. Which admission information is most important in planning this client's nursing care?
. The client's LMP was January 2.
. The client's blood type is A and Rh+.
. The client's hemoglobin is 11 gm/dL.
. The client's blood pressure is 100/64 mm Hg.
Test-Taking Tip
Think about which of the answers represents a risk factor for the pregnancy. Does that answer correspond to a risk factor or a normal value for pregnancy? Note that three options focus on "blood." Choose the option that is different.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is correct because, when using Naegele's rule, this client's EDD is October 8th. This makes the client 41 weeks and 3 days' gestation on admission. This is the most important factor in planning her nursing care since this is a postdates pregnancy. Answer 2 is incorrect because blood type A with Rh+ does not present any problems in client care; but, maternal blood type O and/or Rh– blood types can cause severe jaundice in the newborn due to maternal antibodies that destroy fetal RBCs. Answer 3 is incorrect because hemoglobin of 11 gm/dL is physiological anemia, caused by the increase in plasma volume in pregnancy. It is not a true anemia. Answer 4 is incorrect because this is a normal blood pressure in pregnancy. The maternal blood pressure normally decreases by 5 to 10 mm Hg in both systolic and diastolic pressures. This decrease is due to peripheral vasodilation caused by pregnancy hormones.