Maternity NCLEX Review 101-

The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area? 1. Vulva 2. Fingers 3. Around the eyes 4. Around the abdomen

1. Vulva Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion.

The nurse assists a pregnant client with cardiac disease in identifying 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 to accomplish which? 1. Help the mother prepare for labor and delivery. 2. Reduce excessive maternal stress and fatigue. 3. Avoid exposure to potential pathogens and resulting infections. 4. Prepare the 18-month-old child for maternal separation during hospitalization.

2. Reduce excessive maternal stress and fatigue. Rationale: 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. Use of appropriate resources will help the client avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Options 1, 3, and 4 are not primary purposes for use of resources with the pregnant cardiac client.

The parents of a neonate who is not circumcised request information on how to clean the newborn's penis. Which is the correct response for the nurse to make to the parents? 1."Retract the foreskin and cleanse with every diaper change." 2."Retract the foreskin and cleanse the glans when bathing the neonate." 3."Avoid retracting the foreskin to cleanse the glans because this may cause adhesions." 4."Retract the foreskin no farther than it will easily go and replace it over the glans after cleaning."

3."Avoid retracting the foreskin to cleanse the glans because this may cause adhesions." Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. Separation should be allowed to occur naturally, which will take place between 3 years and 5 years of age. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone? 1. "It softens the muscles and joints of the pelvis." 2. "It is the primary hormone of milk production." 3. "It maintains the uterine lining for implantation." 4. "It increases during pregnancy to stimulate basal metabolic rate."

4. "It increases during pregnancy to stimulate basal metabolic rate." Rationale: Thyroxine increases during pregnancy to stimulate basal metabolic rates. Relaxin is the hormone that softens the muscles and joints of the pelvis. Prolactin is the primary hormone of milk production. Progesterone maintains uterine lining for implantation and relaxes all smooth muscle including the uterus.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety? 1.Emphasize the technical aspects of this type of delivery. 2.Decide how soon the client should see the baby after delivery. 3.Decrease the partner's anxiety by keeping him or her in the waiting area. 4.Encourage the client to discuss her concerns and desires regarding anesthesia options.

4.Encourage the client to discuss her concerns and desires regarding anesthesia options. Rationale: Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse that do not involve client input. A woman undergoing cesarean delivery often feels disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help alleviate these feelings. Too much technical information may increase the client's anxiety. The presence of a support person is helpful.

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse should include which in the plan of care? 1.Administer antibiotics. 2.Maintain complete bed rest. 3.Notify the neonatal resuscitation team. 4.Maintain continuous electronic fetal monitoring.

4.Maintain continuous electronic fetal monitoring. Rationale: Maternal and fetal well-being are monitored before and during oxytocin administration and includes monitoring fetal heart rate, uterine contractions and tone, and maternal blood pressure. No data in the question indicate the presence of maternal or fetal complications that would require antibiotics, complete bed rest, or notifying the neonatal resuscitation team.

The clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection? 1. A 33-year-old gravida III 2. An adolescent with multiple heterosexual contacts 3. A 25-year-old client with a history of spontaneous abortions 4. A multigravida with a history of repeat cesarean deliveries

2. An adolescent with multiple heterosexual contacts Rationale: Although all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors. The client profiles in options 1, 3, and 4 identify at-risk situations for a variety of obstetric risk factors but not necessarily HIV infection.

The nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route? 1.Intradermal 2.Intratracheal 3.Subcutaneous 4.Intramuscular

2.Intratracheal Rationale: Respiratory distress is common in premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated? 1. 1 to 2 cm 2. 3 to 4 cm 3. 5 to 7 cm 4. 8 to 10 cm

4. 8 to 10 cm Rationale: During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

The nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount? 1. One pad a day 2. Two pads a day 3. Three pads a day 4. Eight pads a day

4. Eight pads a day Rationale: The normal amount of lochia may vary with the individual but should never exceed eight pads a day. The average number of pads used daily is six.

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling my infant on a hip." 2. "Catheterization will be necessary if my infant does not void." 3. "Vital signs should be taken daily to check for bladder infection." 4. "Circumcision has been delayed to save tissue for surgical repair."

4. "Circumcision has been delayed to save tissue for surgical repair." Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. The incorrect option is unrelated to this disorder.

The nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure? 1. Inject at a 45-degree angle. 2. Use a 22-gauge, 1-inch needle for the injection. 3. Do not massage the injection site after administration. 4. Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute.

4. Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute. Rationale: Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ⅝-inch needle. It is injected into skin that has been cleansed or allowed to alcohol dry for 1 minute to remove organisms and prevent infection. It is given at a 90-degree angle. The site is massaged after removing the needle to increase absorption.

The advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply. 1. Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia 4. Blockade of sympathetic fibers 5. Increased voluntary expulsive efforts 6. Decreased incidence of bladder atony

1. Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia Rationale: Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include onset of anesthesia in 1 to 3 minutes, ease of administration, and absence of fetal hypoxia. A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which would most likely indicate a hematoma? 1.Changes in vital signs 2.Signs of heavy bruising 3.Complaints of a tearing sensation 4.Complaints of lower abdominal discomfort

1.Changes in vital signs Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted? 1.Fetal tachycardia 2.Increased urinary output 3.Contractions occurring every 3 minutes 4.Soft uterine tone palpated between contractions

1.Fetal tachycardia Rationale: Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia because of excessive uterine activity. The nurse should also ensure that the uterus maintains an adequate resting tone between contractions. Options 2, 3, and 4 are not indications of a problem.

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect? 1. Less pressure on her cervix 2. Increased efficiency of contractions 3. Decreased number of contractions 4. The need for increased blood pressure (BP) monitoring

2. Increased efficiency of contractions Rationale: Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not create the need for increased monitoring of the BP.

Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication? 1. Milk production 2. Uterine contractions 3. Increased urinary output 4. Decreased afterbirth pains

2. Uterine contractions Rationale: Oxytocin stimulates uterine contractions and is administered to reduce the incidence of hemorrhage after expulsion of the placenta. It does not directly affect urinary output or milk production. The subsequent contraction of the uterus may cause an increase in the afterbirth pains.

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks? 1. 6 to 8 2. 8 to 10 3. 12 to 16 4. 20 to 22

3. 12 to 16 Rationale: By the end of the twelfth week, the fetal gender can be determined by the appearance of the external genitalia on ultrasound.

The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which medication is prescribed? 1. Subcutaneous administration of terbutaline 2. Oral intake of 15 mg of warfarin (Coumadin) daily 3. Intravenous infusion of heparin sodium 5000 units daily 4. Subcutaneous administration of heparin sodium 5000 units daily

4. Subcutaneous administration of heparin sodium 5000 units daily Rationale: Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antepartum, intrapartum, and postpartum periods. Warfarin is contraindicated during pregnancy because it crosses the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not cross the placental barrier, is safe to use during pregnancy and would be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only.

The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which? 1. Placing external fetal monitors so that each fetal heart rate is monitored separately 2. Placing the external fetal monitor over the fetus that is most anterior to the mother's abdomen 3. Placing the external fetal monitor over the fetus that is most posterior to the mother's abdomen 4. Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus

1. Placing external fetal monitors so that each fetal heart rate is monitored separately Rationale: In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 2, 3, and 4 are incorrect because these actions would not provide information regarding the status of each fetus.

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip? 1. Age of client 2. Maternal vital signs 3. Last menstrual period 4. A temporary interruption in recording

2. Maternal vital signs Rationale: Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 1 and 3 are irrelevant.

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. Which position should the nurse place the client in? 1. Lying down 2. On the left side 3. On the right side 4. In a sitting position

4. In a sitting position Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. The blood pressure should be obtained in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 2, and 3 are incorrect, and these positions may cause physiological stress that will affect the blood pressure.

The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse should make which statement to address the client's concern? 1. "Don't worry about your baby, complications are rare." 2. "You will not have any problems if you follow the advice the health care provider has given you." 3. "Your baby will need to spend a few days in the neonatal intensive care unit following delivery." 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."

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." Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options 1 and 3 provide false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

Home History Help Calculator Study ModeQuestion 148 of 545 Previous 148 ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client? 1. Expect the baby to move at least 35 times in 3 hours. 2. Lie on the stomach when preparing to count the fetal movement. 3. Schedule the counting periods in the morning when the fetal movement is highest. 4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.

4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours. Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching? 1. Milk 2. Potatoes 3. Cantaloupe 4. Fresh spinach

4. Fresh spinach Rationale: Dietary sources of iron include lean meats; liver; shellfish; dark green, leafy vegetables such as spinach; legumes; whole grains and enriched grains; cereals; and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C.

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which occurs?

4. Irregular, painless contractions Rationale: Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which problem is most likely to occur during this stage? 1.Anxiety related to childbirth 2.Pain because of the process of labor or birth 3.Fatigue resulting from physical exertion during labor 4.Urinary retention caused by the loss of sensation to void and rapid bladder filling

4.Urinary retention caused by the loss of sensation to void and rapid bladder filling Rationale: The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax. Options 1 and 2 relate to the first stage of labor. Option 3 relates to the second stage of labor. Option 4 is related to the third and fourth stages of labor.

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery? 1.Hemoglobin of 11.5 g/dL 2.Fetal heart rate of 154 beats per minute 3.Maternal pulse rate of 90 beats per minute 4.White blood cell count of 35,000 cells/mm3

4.White blood cell count of 35,000 cells/mm3 Rationale: White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 cells/mm3 to 15,000 cells/mm3 up to 18,000 cells/mm3. A count of 35,000 cells/mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of hemodilution caused by an increase in plasma volume during pregnancy. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. A normal fetal heart rate is 120 to 160 beats per minute.

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? 1. "Leopold's maneuvers are used to determine fetal position." 2. "Leopold's maneuvers are used to determine fetal heart rate." 3. "Leopold's maneuvers are used to determine duration of contractions." 4. "Leopold's maneuvers are used to determine frequency of contractions."

1. "Leopold's maneuvers are used to determine fetal position." Rationale: Leopold's maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal position and presentation. Options 2, 3, and 4 are incorrect.

Which safety measures that should be implemented when working in the newborn nursery? Select all that apply. 1.Adhere to standard precautions. 2.Place bassinets 1 foot apart from one another. 3.It is acceptable for nurses who are ill to work in the nursery. 4.An identification bracelet should be placed on the infant only after the initial bath is completed. 5.The parents should be instructed to not release their infant to anyone wearing improper identification. 6. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.

1.Adhere to standard precautions. 5.The parents should be instructed to not release their infant to anyone wearing improper identification. 6.The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room. Rationale: Newborn safety, infection prevention, and abduction prevention are major responsibilities for nurses working in the newborn nursery. Standard precaution guidelines need to be followed to prevent transmission of bacteria and other illnesses to newborns. Following safety precautions to prevent newborn abduction includes footprinting the newborn along with fingerprinting of the mother on the identification card. This also includes placing bracelet identification on the mother and infant before removing the newborn from the delivery room. Educating parents to release their newborn only to those wearing proper identification is key in preventing newborn abductions in the inpatient situation. Bassinets are to be 3 feet apart. Nurses who are ill should not be working in the nursery.

The nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? 1. A soft and boggy uterus 2. Changes in the shape of the uterus 3. Maternal complaints of severe uterine cramping 4. The umbilical cord shortens in length and changes in color

2. Changes in the shape of the uterus Rationale: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness but not sudden uterine cramping.

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean delivery. 4. Eliminate the need for analgesic administration.

2. Prevent dehydration and hypoxemia. Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which? 1. A normal finding 2. The presence of infection 3. The need for increasing oral fluids 4. The need for increasing ambulation

2. The presence of infection Rationale: Lochia, the discharge present after birth, is red the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor of menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids and ambulate are not accurate interpretations related to the assessment finding.

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time? 1. Inability to cope 2. Deficient sensory perception 3. Fear about what is happening 4. Lack of control over the situation

3. Fear about what is happening Rationale: The mother is anxious and frightened and the most appropriate problem for the client at this time is fear about what is happening. No data in the question support the problems noted in the other options although they may be a consideration for this client at some point during the hospitalized experience.

The nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. Which complication would the client be at risk for? 1. Coagulopathy 2. Postpartum infection 3. Chronic hypertension 4. Postpartum hemorrhage

4. Postpartum hemorrhage Rationale: Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse monitors the client frequently for signs of postpartum hemorrhage. Options 1, 2, and 3 are not directly associated with placenta previa.

The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action? 1. Have the client stand for the procedure. 2. Assist the client from a sitting to a right lateral position. 3. Place the client in a prone position with the head of the bed elevated. 4. Place the client in a supine position and place a wedge under the right hip.

4. Place the client in a supine position and place a wedge under the right hip. Rationale: When measuring fundal height, the client lies in a supine position, and the nurse places a wedge under the right hip. This position will assist in preventing supine hypotension. Options 1, 2, and 3 are incorrect client positions for measuring fundal height.

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

1. "Tell me what you mean when you say that your baby has moved." Rationale: Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 1 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 2, 3, and 4 do not and are blocks to communication.

The nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which?1. Estrogen 2. Prolactin 3. Progesterone 4. Human chorionic gonadotropin (hCG)

1. Estrogen Rationale: The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish tinge that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what? 1. General anesthesia 2. To be left totally alone 3. To push with her contractions 4. To regain her breathing pattern

4. To regain her breathing pattern. Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated. The client may be terrified of being left alone during this phase of labor.

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is which? 1. Flat and unfavorable for a vaginal birth 2. Rounded and most favorable for a vaginal birth 3. Narrow and oval and not the most favorable for a vaginal birth 4. Wedge-shaped and narrow and unfavorable for a vaginal birth

4. Wedge-shaped and narrow and unfavorable for a vaginal birth Rationale: The android pelvic shape is wedge-shaped and narrow and is an unfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is an unfavorable shape for a vaginal birth.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. According to the nurse, what is the purpose of progesterone? 1. Progesterone maintains the uterine lining for implantation. 2. Progesterone stimulates metabolism of glucose and converts the glucose to fat. 3. Progesterone prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 4. Progesterone stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

1. Progesterone maintains the uterine lining for implantation. Rationale: Progesterone maintains the uterine lining for implantation and relaxes smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that supports and protects the internal reproductive organs. The student correctly responds by identifying which structure? 1. Ovaries 2. Pelvis 3. Vagina 4. Fallopian tube

2. Pelvis Rationale: The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs. The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle. The vagina allows discharge of the menstrual flow, is the female organ of coitus, and allows the passage of the fetus from the uterus to outside the mother's body during childbirth. The fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward the uterine cavity to propel the ovum through the tube.

The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration? 1. "It will help relax the muscles of my uterus." 2. "It will help relieve the nausea I'm experiencing." 3. "It will help me produce more milk for breast-feeding." 4. "It will help prevent and control bleeding if it occurs."

4. "It will help prevent and control bleeding if it occurs." Rationale: Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used in the postpartum period to stimulate the uterus to contract and prevent or control postpartum hemorrhage. Options 1, 2, and 3 are incorrect actions of the medication.

The nurse has reinforced instructions to a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure? 1. Washes and dries her hands before feeding 2. Requests that the window be closed before feeding 3. Holds the infant properly during feeding and burping 4. Tests the temperature of the formula before initiating feeding

1. Washes and dries her hands before feeding Rationale: Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in prevention of the transmission of infection. Option 2 will not affect disease transmission. Options 3 and 4 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client? 1. The client exhibits no signs of fetal distress. 2. The client expresses an understanding of her condition. 3. The client identifies and uses available support systems. 4. The client demonstrates compliance with activity limitations.

1. The client exhibits no signs of fetal distress. Rationale: Option 1 clearly identifies a physiological need. Options 2, 3, and 4 may be components of the plan of care, but the physiological integrity and safety of the mother newborn dyad are the priorities.

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position? 1. Trendelenburg's with the legs in stirrups 2. Supine with a wedge under the right hip 3. Prone with the legs separated and elevated 4. Semi-Fowler's with a pillow under the knees

2. Supine with a wedge under the right hip Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this should be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's, prone, or Trendelenburg's position with the legs in stirrups is not practical for this type of abdominal surgery.

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose? 1. Reduce a backache. 2. Prevent ankle edema. 3. Prevent urinary tract infections. 4. Strengthen the pelvic floor in preparation for delivery.

4. Strengthen the pelvic floor in preparation for delivery. Rationale: Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help reduce backaches. Instructing a client to drink 8 ounces of fluids 6 times a day will help prevent urinary tract infections. Leg elevation will assist in preventing ankle edema.

The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation? 1. The spouse if grieving because of the loss of the baby. 2. The spouse is anxious about the reason the baby died. 3. The spouse does not have any knowledge about the disease process. 4. The spouse lacks hope because of the loss of the baby and illness of his wife.

4. The spouse lacks hope because of the loss of the baby and illness of his wife. Rationale: A person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the situation of grieving, deficient knowledge, or anxiety.

The clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs? 1. Offering praise and reinforcement for compliance with treatment therapies 2. Providing the mother with pamphlets and booklets to read about the pregnancy 3. Using a caring and supportive approach when dealing with the pregnant woman 4. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy

2. Providing the mother with pamphlets and booklets to read about the pregnancy Rationale: The woman's emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse should also discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Option 2 would least likely assist in meeting the emotional needs of the woman.

Home History Help Calculator Study ModeQuestion 123 of 545 Previous 123 ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client? 1. Up in chair 2. Ambulation 3. Complete bed rest 4. Bathroom privileges

3. Complete bed rest Rationale: Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions.

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure? 1. "I'm getting tired of lying flat on my back." 2. "I shut the machine off when I talk on the telephone." 3. "What an efficient way to record my baby's heart rate." 4. "How many volts of electricity are going through my body?"

3. "What an efficient way to record my baby's heart rate." Rationale: EFM is a method of recording the fetal heart rate. The woman is asked to assume a semisitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface; in this case, the fetal heart and valves. No electricity or voltage goes through the body. EFM does not need to be shut off when talking on the telephone.

The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate? 1. Elevate the head of the bed. 2. Obtain a hemoglobin and hematocrit level. 3. Instruct the mother to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of lightheadedness and dizziness have subsided.

3. Instruct the mother to request help when getting out of bed. Rationale: Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness and dizziness are signs that caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times getting out of bed. Option 1 is not a helpful action and could cause increased dizziness. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement? 1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement." 2. "I should drink 8 to 12 glasses of liquid a day, and I can count the coffee that I drink." 3. "I should drink 8 to 12 glasses of liquid a day, and I can count the tea, fruit juices, or milk that I drink." 4. "I should drink 8 to 12 glasses of liquid a day, and I can count the carbonated soft drinks that I consume."

1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement." Rationale: The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation: 8 to 12 glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.

The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal? 1. Minimize the possibility of preterm labor. 2. Reduce the risks of anemia during pregnancy. 3. Avoid further stress on the maternal immune system. 4. Minimize the risk of premature rupture of membranes.

3. Avoid further stress on the maternal immune system. Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 3 identifies the primary nursing management subject for the HIV-infected client.

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is which? 1. Flat and unfavorable for a vaginal birth 2. Rounded and most favorable for a vaginal birth 3. Narrow and oval and not the most favorable for a vaginal birth 4. Wedge-shaped and narrow and unfavorable for a vaginal birth

1. Flat and unfavorable for a vaginal birth Rationale: The platypelloid pelvic shape is flattened with a wide, short oval shape and is an unfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The android pelvic shape is wedge-shaped and narrow and is an unfavorable shape for a vaginal birth.

A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise in which to engage? 1. Swimming 2. Scuba diving 3. Low-weight gymnastics 4. Bicycling with the legs in the air

1. Swimming Rationale: Non-weight-bearing exercises are preferable to weight-bearing exercises. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non-weight-bearing exercise such as swimming is allowable. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided.

The nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. Which instructions should the nurse give the women with regard to performing the procedure? 1. Contracting and then consciously relaxing different muscle groups 2. Massaging the abdomen during contractions using both hands in a circular motion 3. Instructing the significant other to stroke or massage a tightened muscle by the use of touch 4. Contracting an area of the body such as an arm or leg and then concentrating on letting tension go from the rest of the body

2. Massaging the abdomen during contractions using both hands in a circular motion Rationale: Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Touch relaxation helps the woman to learn to loosen taut muscles when she is touched by her partner. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg then concentrates on letting tension go from the rest of the body.

A pregnant woman visiting a health care clinic for the first prenatal visit hears the health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. How does the nurse describe the preembryonic period for the client? 1. "The preembryonic period is the period of time before conception." 2. "The preembryonic period is the longest period of fetal development." 3. "The preembryonic period is the first 2 weeks of fetal development following conception." 4. "The preembryonic period is the fetal development period from the beginning of the third week through the eighth week after conception."

3. "The preembryonic period is the first 2 weeks of fetal development following conception." Rationale: The preembryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period. The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form.

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, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should be appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Instruct the client that these are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3. Instruct the client that these are common and may occur throughout the pregnancy. Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some women during pregnancy, options 1, 2, and 4 are unnecessary and inaccurate.

A client had a cesarean delivery with a low transverse uterine incision. Which is the benefit of this type of incision? 1. It requires that a vertical skin incision be made. 2. It can be extended if a larger incision is needed. 3. It is the best choice with a placenta previa on the lower anterior uterine wall. 4. It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.

4. It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy. Rationale: A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision.