Fluid management during the first 24 hours following a burn injury generally includes the

infusion of a balanced salt solution, usually lactated Ringers solution. Fluid resuscitation is
determined by urine output and hourly urine output should be at least 30 mL/hr. The clients
urine output is indicative of insufficient fluid resuscitation, which places the client at risk for
inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the
physician would prescribe an increase in the amount of IV lactated Ringers solution
administered per hour. Administering a diuretic would not correct the problem because it
would not replace needed fluid. Diuretics promote the removal of the circulating volume,
thereby further compromising the inadequate tissue perfusion. Dextrose in water is an
isotonic solution and an isotonic solution maintains fluid balance. This type of solution may be
administered after the first 24 hours following the burn injury, depending on the clients
physiological needs. Blood replacement is not consistent with fluid therapy for burn injuries.
The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L
indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid
foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of
phosphorus. Processed foods are high in sodium content.
A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg,
spinach (3 oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.
The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This
will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular
disorders later in life. Options 3 and 4 are elevated values and place the client at risk for
cardiovascular disease. Although option 1 is a low cholesterol level, option 2 identifies the
realistic value to assist in preventing cardiovascular disease.
In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to
8% indicates fair control, and 8% or higher indicates poor control. This test measures the
amount of glucose that has become permanently bound to the red blood cells from circulating
glucose. Elevations in the blood glucose level will cause elevations in the amount of
glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia
that are undetected in other ways. Elevations indicate continued need for teaching related to
the prevention of hyperglycemic episodes.
Vegans do not consume any animal products. Vitamin B12 is found in animal products and
therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh
fruits and vegetables, which are consumed in a vegan diet.
Fruits and vegetables tend to be lower in fat because they do not come from animal sources.
Fish is also naturally lower in fat. Cream cheese is a high-fat food.
The type of planning and instruction required varies with each individual and the type of
surgery. Specific instructions that the client needs to receive before discharge should include
wound care, activity restrictions, dietary instructions, postoperative medication instructions,
personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the
preoperative period.
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.

 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) 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.
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.
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.
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 Goodells 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.
Goodells sign does not indicate the presence of fetal movement.
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 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.
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 soft-textured clothing to decrease nipple tenderness and to use breast pads
inside the bra to prevent leakage if colostrum is a problem.

 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 flat-heeled 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 center of
gravity because of the enlarged uterus. Performing more exercises to strengthen the back
muscles could be harmful to a pregnant client.
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. Nonweight-bearing exercises such as swimming are allowable.
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 betweenmeal 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 gasproducing 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 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.

 Rubella vaccine is administered to women who have not had rubella or women who are not
serologically immune. The vaccine may be administered in the immediate postpartum period
to prevent the possibility of contracting rubella in future pregnancies. The live attenuated
rubella virus is not communicable in breast milk; therefore, breast-feeding does not need to
be stopped. The client is counseled not to become pregnant for 1 to 3 months following
immunization as specified by the health care provider because of a possible risk to a fetus
from the live virus vaccine; the client must be using effective birth control at the time of the
immunization. The client should avoid contact with immunosuppressed individuals because of
their low immunity toward live viruses, because the virus is shed in the urine and other body
fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can
occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There
is no useful or necessary reason for covering the area of the injection with sterile gauze.
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 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.
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 maternal infection or prepare the client and family for
the subsequent labor, delivery, and hospitalization.

Level of Cognitive Ability - Application

Client Needs - Health Promotion and Maintenance
Integrated Process - Nursing ProcessImplementation
Content Area - MaternityAntepartum

True labor for a multiparous client is present when the contractions increase in duration and
intensity. A multiparous client experiences true labor before the fetus engages. Contractions
felt in the abdominal area and contractions that ease with walking are signs of false labor.

Level of Cognitive Ability - Analysis

Client Needs - Health Promotion and Maintenance
Integrated Process - Nursing ProcessEvaluation
Content Area - MaternityIntrapartum