EVOLVE ANTEPARTUM

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman?

4. "You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed."

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. The nurse should tell that client that which exercise is safest?

1. Swimming

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply.

1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 5. "The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy."

A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction?

4. "I should do more exercises to strengthen my back muscles."

A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms?

4. Eating dry crackers before arising

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action?

4. Initiate a gentle upward tap on the cervix.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)?

4. The client complains of a headache and blurred vision.

The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid?

4. Green leafy vegetables

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data should alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? Select all that apply.

1. The client's last baby weighed 10 lb at birth. 5. The client has a history of gestational diabetes with her previous pregnancy.

A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information?

4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

1. "I should lie on my back to perform the procedure."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

1. "I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nurse is assisting the health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure?

1. Ask the client to urinate.

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections?

1. Establish a therapeutic relationship.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?

1. The client's last baby weighed 10 pounds at birth.

The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd).

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The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2018. Using Nägele's rule, the nurse determines that what is the estimated date of delivery? Fill in the blank. Record your answer using 6 digits (mmddyy).

111618

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?

2. "Bend your foot toward your body while extending the knee when the cramps occur."

A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate?

2. "Breast-feeding is allowed after the baby has been vaccinated with immune globulin."

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

2. "Do you plan to have any other children?"

The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What should be the nurse's response?

1. "Prolactin stimulates the secretion of milk, which is called lactogenesis."

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?

3. "The iron is best absorbed if taken on an empty stomach."

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment?

3. The client has a history of hypertension.

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client?

4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem?

4. "I will eat fresh fruits and vegetables for snacks and for dessert each day."

The nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur?

3. She will feel some pressure when the vaginal probe is moved.

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply.

3. The breast changes occur because of the secretion of estrogen and progesterone. 5. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida.

A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction?

2. "I should drink unpasteurized milk only."

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan?

2. Reduce external stimuli.

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?

3. "The iron is best absorbed if taken on an empty stomach."

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action?

3. Place the fetal heart monitor on the client in order to do a nonstress test (NST).

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem?

4. "I want to gain only 10 pounds because I want to have a small, petite baby."

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?

4. "I will eat fresh fruits and vegetables for snacks and for dessert each day."

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?

4. "I should avoid eating foods that produce gas and fatty foods."

A primigravida asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

4. 18 and 20

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium?

2. Broccoli

The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food?

2. Dried fruits

The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that it is 99.2°F. Based on this finding, which nursing action is most appropriate?1. Document the temperature.

1. Document the temperature.

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise should the nurse instruct the client to engage in?

1. Swimming

The nurse is describing cardiovascular system changes that occur during pregnancy to a client. Which findings are normal for a client in the second trimester? Select all that apply.

1. Increase in pulse rate 4. Increase in red blood cell production

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment?

1. Increased insulin

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit?

1. Monitor for fetal movement.

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to Figure. (Figure from McKinney et al. [2013], p. 310.)

1. Normal

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result?

1. Normal findings

The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply.

2. Abdominal pain 4. Firm uterus by palpation

A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action?

2. Assess for signs of venous thrombosis.

The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply.

2. Painless, bright red vaginal bleeding 3. Location in the lower uterine segment

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

2. The client has a history of cardiac disease.

A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply.

2. The client is wearing knee-high nylon stockings. 5. The client is wearing sweatpants with snug elastic ankle bands.

The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching?

3. "I should apply heat packs to the hemorrhoids to help them shrink."

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider (HCP). The nurse should tell the woman to call the HCP if which occurs?

3. Weight increases by more than 1 pound in a week.

The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet?

4. Leafy green vegetables

The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents?

4. Monitor for appropriate weight gain patterns.

Which is the priority nursing action for the client with an ectopic pregnancy?

4. Monitoring the pulse and blood pressure

The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item?

4. Orange juice

The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which drink?

4. Orange juice

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply.

3. The breast changes occur because of the secretion of estrogen and progesterone. 5. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida.

The nurse provides teaching on how to relieve discomfort to a client in her second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching?

4. "When I get home I should lie on the floor, with my legs elevated on a couch, and turn my hips and knees at right angles."

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction?

4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention?

3. Document findings in the electronic health record.

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Based on her last normal menstrual period, she is 8 weeks' gestation. Appropriate physical assessments are completed. Which findings are anticipated to be present at this time? Select all that apply.

1. A softening of the cervix 3. Bluish discoloration of the vaginal tissue 4. The presence of human chorionic gonadotropin in the urine

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

2. G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion?

2. History of syphilis

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

2. Isoniazid plus rifampin will be required for 9 months

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart?

2. July 26, 2019

The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action?

2. Massaging the abdomen during contractions, using both hands in a circular motion

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart below. History and Physical Laboratory and Diagnostic Results Medications Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Venereal Disease Research Laboratory (VDRL) nonreactive Prenatal vitamins Weight 135 lb (61 kg) Rubella immune Positive Goodell and Chadwick Rh positive, Type O

3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

3. A private room 2 doors away from the nurses' station

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

3. Inform the client that these contractions are common and may occur throughout the pregnancy.

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply.

3. It is the way the baby gets food and oxygen. 5. It provides an exchange of nutrients and waste products between the mother and developing fetus.

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instruction?

4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply

3. Fetal heart rate of 180 beats/minute 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide?

2. Wash the breasts with warm water and keep them dry.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

3. An informed consent needs to be signed before the procedure.

The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign?

3. Bluish discoloration of cervix and vagina

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching?

3. "I cannot exercise because of the negative effects on insulin production."

The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman indicates that further teaching is required?

3. "I will eat dry crackers for breakfast after I get up."

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

3. "It connects the umbilical vein to the inferior vena cava."

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client?

3. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated."

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy, and the client asks the nurse about the procedure. How should the nurse respond to the client?

3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the sex of the fetus is determined by which weeks?

3. 12 to 16

The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)?

3. 32 cm

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication?

3. Abruptio placentae

A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond?

4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client?

4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

The nurse is providing instructions regarding the treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction?

4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

4. "I should drink adequate fluids and increase my intake of high-fiber foods."

A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly?

4. "I will need to prepare myself and my family for the loss of this pregnancy."

The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures?

4. "It may be necessary to have a cesarean section for delivery."

A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response?

4. "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine."

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make?

4. Between 16 and 20 weeks

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.

1. Proteinuria 2. Hypertension

The clinic nurse is teaching a pregnant woman about the warning signs in pregnancy. Which, if identified as a warning sign by the woman, should indicate a need for further education?

4. Presence of irregular, painless contractions

The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason?

1. Reduce excessive maternal stress and fatigue.

A client calls the health care provider's office to schedule an appointment because she has missed 2 menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse should expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply.

1. Chadwick's sign 3. Positive pregnancy test

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

4. 18 weeks

A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 99°F. The nurse plans care based on which interpretation?

1. The woman requires further evaluation for preterm labor.

The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply.

1. Vaginal bleeding 3. Excessive nausea and vomiting 4. Larger-than-normal uterus for gestational age 5. Elevated levels of human chorionic gonadotropin (hCG)

The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply.

1. Viruses 3. Nutrients 4. Antibodies 5. Medications

A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2018, and ended the menses on March 14, 2018. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy).

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The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?

2. "I need to lie flat on my back to perform the procedure."

A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs?

2. "I should avoid stressful situations."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

3. "I should avoid exercise because of the negative effects on insulin production."

A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching? Select all that apply.

3. An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. 4. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation.

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply.

3. Fetal heart rate of 180 beats/minute t 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)

The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority?

3. Insufficient fluid volume

The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching?

4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

A 39-week-gestation pregnant client calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse?

4. "Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your health care provider for further evaluation."

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?

4. "I don't like my face anymore. I always look like I have been crying."

A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement?

4. "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water."

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures?

4. "I should wear underwear with a cotton panel liner."

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain?

4. Calcium gluconate injection

The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?

4. Dried peas

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider (HCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the HCP has documented the results as negative. How should the nurse interpret this finding?

1. A normal test result

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension?

1. "My vision for the past 2 days has been really fuzzy."

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply.

1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement?

1. "An increase in pulse rate occurs."

During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement?

1. "Diet and insulin needs change during pregnancy."

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

1. A normal test result

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.

1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?

1. Apply heat to the affected area

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply.

1. Assess blood pressure. 2. Check the urine for protein. 3. Assess deep tendon reflexes. 5. Teach the importance of keeping track of a daily weight.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test

The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding?

1. Fundus is at the appropriate level.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of first trimester pregnancy signs. Which signs should the nurse anticipate as being present during this time frame? Select all that apply.

1. Hegar's sign 4. Goodell's sign 5. Chadwick's sign

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that which may be required during the second half of pregnancy?

1. Increased insulin

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia?

1. Maternal infection

The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply.

1. Places the client at risk for dystocia 2. Has an increased probability of cesarean section 5. Has a flat shape that may impede fetal descent

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk?

1. Presence of cats in the home

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor?

1. The appearance of the fetal external genitalia

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.

1. The client has a history of intravenous drug use. 2. The client has a significant other who is heterosexual. 3. The client has a history of sexually transmitted infections.

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?

2. "I will maintain strict bed rest throughout the remainder of the pregnancy."

A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply.

2. "It is the fetal movement that is felt by the mother." 5. "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20."

The nursing instructor asks a nursing student who is preparing to assist with the assessment of an 18 weeks' gestation gravida 2, para 1 (G2P1) pregnant woman to describe expectations related to the process of quickening. Which statements, if made by the student, indicate an understanding of this process? Select all that apply.

2. "It is the fetal movement that is felt by the mother." 5. "It is typically experienced by the multigravida client between 16 and 18 weeks' gestation."

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

2. "The vaginal discharge may be bothersome, but is a normal occurrence."

A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? Select all that apply.

2. "This test can be used as a screening for spina bifida." 3. "One of the purposes of this test is to determine the sex of my baby." 4. "This test is a screening test, and I will need other testing if I have abnormal results." 5. "This test can indicate if I may be at an increased risk for having a child with Down syndrome."

A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response?

2. "This test measures amniotic fluid volume and fetal activity."

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

2. "Your type of pelvis is the most favorable for labor and birth."

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period?

2. A 26-year-old client with a family history of thrombophlebitis

A pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. Which activity should the nurse tell the client to perform when the cramps occur?

2. Dorsiflex the foot while extending the knee.

The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure?

2. Drink 8 glasses of water per day

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate?

2. Notify the health care provider (HCP).

A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client?

2. Pain, itching, and vaginal discharge

Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?

2. Phenytoin

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? 2. Retesting rubella titer during pregnancy

2. Retesting rubella titer during pregnancy

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply.

2. Routine administration of subcutaneous heparin may be prescribed. 3. An overbed lift may be necessary if the client requires a cesarean section. 4. Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

The nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid?

2. Spinach

The charge nurse on a labor and delivery unit has numerous admissions of laboring clients and must transfer 1 of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client is the most appropriate one to transfer?

2. The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding

A client in week 35 of her pregnancy is placed on the fetal heart monitor for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes which conclusion regarding the NST? Refer to Figure. (From McKinney et al. [2013], p. 319.)

2. The FHR is reactive, with a baseline of 130 beats/minute, moderate variability, and no decelerations.

A pregnant client calls the nurse at the health care provider's office and reports that she has noticed a thin, colorless vaginal drainage. Which information is most appropriate for the nurse to provide to the client?

2. The vaginal discharge may be bothersome but is a normal occurrence.

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.

2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID)

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved?

3. Complaints of daily headaches and fatigue

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice?

3. Hemoglobin 9 g/dL (90 mmol/L)

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse implement?

3. Instruct the client that these are common and may occur throughout the pregnancy

A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. A sputum culture is obtained, and Mycobacterium tuberculosis is identified in the sputum. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis?

3. Isoniazid plus rifampin will be required for a total of 9 months

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen? Select all that apply.

3. It increases the blood flow to mucous membranes and causes them to swell and soften. 5. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority?

3. Monitoring the apical pulse

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

3. Notify the health care provider (HCP).

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction?

3. Restrict visitors who may have an active infection.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?

3. The client is measuring normal for gestational age.

A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client?

4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply.

4. "The exercises will help strengthen the pelvic floor in preparation for delivery." 5. "The exercises will help strengthen the muscles that support the bladder and urethra."

A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure?

4. "The procedure is performed using artificial insemination of sperm instilled through the vagina."

The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?

4. "This is necessary to assist in identifying potential infections that may need to be treated."

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response?

4. "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client?

4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?

4. Compression of the vena cava

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

4. Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply.

4. Plan for weekly nonstress tests at 32 weeks. 5. Obtain nutritional counseling with a dietitian.

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse?

4. Respiratory rate of 10 breaths/minute

A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth?

4. Striae gravidarum

The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron?

4. Whole-grain cereal

The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time? Select all that apply.

5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1.