NCLEX Antepartum Saunders

A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client would indicate the need for further teaching

"It is best to rest on my right side."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

A pregnant client 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 bases the response on what information?

he breast changes are a result of the secretion of estrogen and progesterone.

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?

he client will not develop an opportunistic infection during the remainder of pregnancy.

The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breast-feed the infant after delivery. Which response by the nurse is appropriate?

"Breast-feeding is contraindicated."

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, which is the best response by the nurse?The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?

"Can you tell me more about what you are eating?"

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

"Do you plan to have any other children?"

The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation?

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

The nurse employed in a health care provider's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral?

"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?

"I need to gain only 10 pounds so that my baby will be small like I am."

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

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

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?

"It increases during pregnancy to stimulate basal metabolic rate."

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?

"The preembryonic period is the first 2 weeks of fetal development following conception."

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?

Administration of immune globulin and vaccine in the infant soon after birth

The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone?

"It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."

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

"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 woman at 20 weeks of gestation calls the health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"This is an emergency; you should come to the clinic within the hour."

A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the health care provider to prescribe?

Amniocentesis for fetal surfactant level

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?

12 to 16

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. She also wants to know when she can hear the fetus's heartbeat with a fetoscope rather than a Doppler. During which time frame will the client both hear the heartbeat with a fetoscope and feel the fetus move?

16 and 20 weeks of gestation

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week?

28

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week? Fill in the blank.

5

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

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

When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors would the nurse consider significant?

A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago

The nurse is collecting data from a prenatal client. The nurse determines that which places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

A history of intravenous (IV) drug use in the past year

The nurse notes that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which is the explanation for this increase?

A normal finding

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?

A softening of the cervix

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which findings would place the client at risk for preterm labor?

A urinary tract infection

A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?

Abdominal pain

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation?

Acute anxiety and the need for support

A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation?

Adding 1 tablespoon of mineral oil to a bowl of cereal daily

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data?

Weight and height

The nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?

Assists in identifying infections that may need to be treated

A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?

Avoid exposure to litter boxes used by cats.

The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food item?

Beans

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply

Bypassing the fetal lungs to circulate oxygen rich blood Using the fetus's beating heart to pump blood in the circulatory system Carrying more oxygen on fetal hemoglobin than maternal hemoglobin Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

Which history would place a maternity client at risk for uterine rupture?

Cesarean section birth

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which?

Compression of the vena cava

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava

The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply

Curtail exercise. Measure your blood pressure daily. Rest frequently by lying on your side. Call the health care provider if you develop dizziness.

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority

Dehydration

The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?

Describing the appropriate amount of weight gain required during the pregnancy

The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take?

Document the assessment.

The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?

Document the temperature.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.

Edema Proteinuria Thrombocytopenia

The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description characterizes the purpose of estrogen?

Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time?

Explain the purpose of the nurse's actions and answer all questio

The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the health care provider. Which warning signs would the nurse place on the list? Select all that apply.

Facial edema Rapid weight gain Visual disturbances Generalized edema

The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the health care provider?

Fundal height, 38 cm

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?

Gravida II, para I

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?

Hemoglobin 9.1 g/dL

The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

History of substance abuse during this pregnancy

The nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?

How to check for signs of hypoglycemia and the required treatment

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

he bladder must be full during the exam.

A client calls the health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine?

Human chorionic gonadotropin (hCG)

The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to a potential problem specifically related to the twin pregnancy?

Hypertension

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?

In a sitting position

A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?

Inevitable

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?

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

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?

Irregular, painless contractions

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?

Laser therapy

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right

The nurse is assisting in 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 taking which action?

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

The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?

Maternal hypertension

The nurse is reviewing the health care record of a pregnant client at 16 weeks' gestation. The nurse should expect documentation that the fundus of the uterus is noted at which area?

Midway between the symphysis pubis and the umbilicus

The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?Minimize the potential for developing infections.

Minimize the potential for developing infections.

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?

Minimizing the client's exposure to external stimuli

The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?

Monitoring fetal movement

The nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. Which terms apply to an android pelvis? Select all that apply.

Narrow wedge shape Unfavorable for a vaginal birth

A client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which treatment for acne should be avoided with this client?

Oral tetracycline hydrochloride

The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.

Peanut butter Whole grain bread Omelet with cheese

The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action should the nurse perform first?

Place a wedge pillow under the client's right side

The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action should the nurse perform first

Place a wedge pillow under the client's right side.

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?

Place the client in a supine position and place a wedge under the right hip.

A pregnant woman who is at 38 weeks gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, what does the nurse determine the client may be experiencing?

Placenta previa

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?

Placing external fetal monitors so that each fetal heart rate is monitored separatel

The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother.

The nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that which hormone stimulates the secretion of milk?

Prolactin

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

Providing the mother with pamphlets and booklets to read about the pregnancy

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?

Providing the mother with pamphlets and booklets to read about the pregnancy

During an initial prenatal visit, the nurse notes that the client's hemoglobin level is indicative of iron deficiency anemia. Which additional client data would also support this finding?

Reports of fatigue

The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority

Signs of fetal distress

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?

Swimming

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study would further support the presence of HIV?

T lymphocyte levels

The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action should the nurse take before the procedure to ensure fetal safety?

Test the ultrasound equipment to ensure proper functio

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?

The client complains of a headache and blurred vision.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching

The client is wearing knee-high hose.

The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?

The insulin needs will increase.

The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

During the antenatal period of a client diagnosed with the human immunodeficiency virus (HIV), the nurse result of her rubella screening is positive. routinely and discusses the findings. Which is the primary purpose of this action?

To identify appropriate fetal development

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions would the nurse place on the list? Select all that apply

To note the color of blood on each perineal pad To watch for the evidence of the passage of tissue To note the quantity of blood on each perineal pad To count the number of perineal pads used on a daily basis

A client in the prenatal clinic presents with a blood pressure reading of 134/90 mm Hg, which is an elevation from last month's reading of 104/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?

Trace amount of protein

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic should be a part of the teaching plan for this class?

Travel precautions and use of shoulder seat belts

The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.

Urinary tract infections Increased chance of cesarean birth Delayed lung maturation in the neonate

The nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which finding would support potential further maternal compromise?

Vaginal spotting twice since the last prenatal visit

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?

Vulva

A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which measure is appropriate to suggest to the client?

Wear a perineal pad to the play.