Unit 6 - Antepartum
The nurse is planning an educational session for pregnant vegans. What information should the nurse include? A) Eating beans and rice provides complete protein needs. B) Soy is not a good source of protein for vegans. C) Rice contains a high level of vitamin B12. D) Vegan diets are excessively high in iron.
Answer: A Explanation: A) Adequate dietary protein can be obtained by consuming a varied diet with adequate caloric intake and plant-based proteins. Consuming an assortment of plant proteins throughout the day such as beans and rice, peanut butter on whole-grain bread, and whole-grain cereal with soy milk ensures that the expectant mother obtains all essential amino acids. B) Good sources of plant proteins include beans, soy products, lentils, nuts, and nut butters. C) Vitamin B12 is the cobalt-containing vitamin found only in animal sources. D) Supplementation may be recommended for vegans who have difficulty meeting the recommended amounts of iron through food sources. Page Ref: 296
A pregnant client who was of normal pre-pregnancy weight is now 30 weeks pregnant. She asks the nurse what appropriate weight gain for her should be. What is the nurse's best response? A) "25-35 pounds" B) "30-40 pounds" C) "17-18 pounds" D) "Less than 15 pounds"
Answer: A Explanation: A) An appropriate weight gain for a woman of normal weight before pregnancy would be 25-35 pounds. B) This is not the correct range for woman of normal weight before pregnancy. C) This is not the correct range for woman of normal weight before pregnancy. D) A woman of normal weight before pregnancy should gain more than 15 pounds by 30 weeks. Page Ref: 288
The nurse has completed a community presentation about the changes of pregnancy, and knows that the lesson was successful when a community member states that which of the following is one probable or objective change of pregnancy? A) "Enlargement of the uterus" B) "Hearing the baby's heart rate" C) "Increased urinary frequency" D) "Nausea and vomiting"
Answer: A Explanation: A) An examiner can perceive the objective (probable) changes that occur in pregnancy. Enlargement of the uterus is a probable change. B) Hearing the fetal heart rate is a diagnostic, or positive, change of pregnancy. C) Increased urinary frequency is a subjective, or presumptive, change of pregnancy. D) Nausea and vomiting are subjective, or presumptive, changes of pregnancy. Page Ref: 215
The nurse at the prenatal clinic has four calls to return. Which call should the nurse return first? A) Client at 32 weeks, reports headache and blurred vision. B) Client at 18 weeks, reports no fetal movement in this pregnancy. C) Client at 16 weeks, reports increased urinary frequency. D) Client at 40 weeks, reports sudden gush of fluid and contractions.
Answer: A Explanation: A) Headache and blurred vision are signs of preeclampsia, which is potentially life-threatening for both mother and fetus. This client has top priority. B) Fetal movement should be felt by 19-20 weeks. The lack of fetal movement prior to 20 weeks is considered normal. This client is a lower priority. C) Increased urinary frequency is common during pregnancy as the increased size of the uterus puts pressure on the urinary bladder. D) A full-term client who is experiencing contractions and a sudden gush of fluid is in labor. Although laboring clients should be in contact with their provider for advice on when to go to the hospital, labor at full term is an expected finding. This client is a lower priority. Page Ref: 249
The nurse is preparing a prenatal class about infant feeding methods. The maternal nutritional requirements for breastfeeding and formula-feeding will be discussed. What statement should the nurse include? A) "Breastfeeding requires a continued high intake of protein and calcium." B) "Formula-feeding mothers should protect their health with a lot of calcium." C) "Producing breast milk requires calories, but any source of food is fine." D) "Formula-feeding mothers need a high protein intake to avoid fatigue."
Answer: A Explanation: A) Lactation requires calories, along with increased protein and calcium intake. B) Formula-feeding mothers do not need additional nutrients. C) Although any food source would provide the additional calories, an adequate protein intake is essential while breastfeeding because protein is an important component of breast milk and calcium is an important nutrient in milk production, and increases over non-pregnancy needs are expected. D) Formula-feeding moms do not need additional nutrients. Page Ref: 301—302
The introduction of a new baby into the family is often the beginning of which of the following? A) Sibling rivalry B) Inconsistent childrearing C) Toilet training D) Weaning
Answer: A Explanation: A) Sibling rivalry results from children's fear of change in the security of their relationships with their parents, which comes with the birth of a sibling. B) Consistency is important in dealing with young children. They need reassurance that certain people, special things, and familiar places will continue to exist after the new baby arrives. C) Parents should know that the older, toilet-trained child may regress to wetting or soiling because he or she sees the new baby getting attention for such behavior. D) The older, weaned child may want to drink from the breast or bottle again after the new baby comes. Page Ref: 222
The nurse notes purplish stretch marks on the pregnant client's breasts during the physical assessment. Which term will the nurse use when documenting this finding in the medical record? A) Striae B) Colostrum C) Linea nigra D) Chadwick's sign
Answer: A Explanation: A) Striae is the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. B) Colostrum is not the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. C) Linea nigra is not the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. D) Chadwick's sign is not the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. Page Ref: 208
The nurse is collecting information during the health history assessment for the client profile during the initial prenatal visit. Which question is appropriate when assessing the current pregnancy? A) "What was the date of your last menstrual period?" B) "How many times have you been pregnant?" C) "What were your children's birth weights?" D) "How many living children do you have?"
Answer: A Explanation: A) The nurse would ask the client for the date of the last menstrual period when assessing the current pregnancy as part of the client profile. B) The nurse would ask the client how many times she has been pregnant when assessing past pregnancies as part of the client profile. C) The nurse would assess the birth weights of the client's children when assessing past pregnancies as part of the client profile. D) The nurse would ask the client how many living children she has when assessing past pregnancies as part of the client profile. Page Ref: 241
The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings? A) 12 weeks' gestation, with fetal heart tones heard by Doppler fetoscope B) 22 weeks' gestation, client reports no fetal movement felt yet C) 16 weeks' gestation, fundus three finger-breadths above umbilicus D) Marked edema
Answer: A Explanation: A) This is an expected finding because fetal heart tones should be heard by 12 weeks using a Doppler fetoscope. B) At 22 weeks, no fetal movement is an abnormal finding. Fetal movement should be felt by 20 weeks. C) This is an abnormal finding. The fundus should be three finger-breadths above umbilicus at 28 weeks. D) This is an abnormal finding. There may be some edema of hands and ankles in late pregnancy, but marked edema could indicate preeclampsia. Page Ref: 237
The nurse is preparing for a postpartum home visit. The client has been home for a week, is breastfeeding, and experienced a third-degree perineal tear after vaginal delivery. The nurse should assess the client for which of the following? A) Dietary intake of fiber and fluids B) Dietary intake of folic acid and prenatal vitamins C) Return of hemoglobin and hematocrit levels to baseline D) Return of protein and albumin to predelivery levels
Answer: A Explanation: A) This mother needs to avoid the risk of constipation. She might be hesitant to have a bowel movement due to anticipated pain from the perineal tear, and constipation will decrease the healing of the laceration. B) Dietary intake of prenatal vitamins is important while breastfeeding, but folic acid is more important prior to conception and in the first weeks of pregnancy to prevent neural tube defects. C) It will take several months for the laboratory levels to return to normal. D) It will take several months for the laboratory levels to return to normal. Page Ref: 292
The nurse evaluates the diet of a pregnant client and finds that it is low in zinc. The nurse knows that zinc intake should increase during pregnancy to promote protein metabolism. Which food should the nurse suggest in order to increase intake of zinc? A) Shellfish B) Bananas C) Yogurt D) Cabbage
Answer: A Explanation: A) Zinc is found in greatest concentration in meats, shellfish, and poultry. Other good sources include whole grains and legumes. B) Bananas are high in other nutrients, but do not have significant levels of zinc. C) Yogurt is high in other nutrients, but does not have significant levels of zinc. D) Cabbage is high in other nutrients, but does not have significant levels of zinc. Page Ref: 293
The nurse is assessing a client in the third trimester of pregnancy. What physiologic changes in the client are expected? Select all that apply. A) The client's chest circumference has increased by 6 cm during the pregnancy. B) The client has a narrowed subcostal angle. C) The client is using thoracic breathing. D) The client may have epistaxis. E) The client has a productive cough.
Answer: A, C, D Explanation: A) The chest increase compensates for the elevated diaphragm. B) The diaphragm is elevated and the subcostal angle is increased as a result of pressure from the enlarging uterus. C) Breathing changes from abdominal to thoracic as pregnancy progresses. D) Epistaxis (nosebleeds) may occur and are primarily the result of estrogen-induced edema and vascular congestion of the nasal mucosa. E) A productive cough is never a normal finding. Page Ref: 209
A nurse examining a prenatal client recognizes that a lag in progression of measurements of fundal height from week to week and month to month could signal what condition? A) Twin pregnancy B) Intrauterine growth restriction C) Hydramnios D) Breech position
Answer: B Explanation: A) A sudden increase in fundal height could indicate twins. B) A lag in progression of measurements of fundal height from month to month could signal intrauterine growth restriction (IUGR). C) A sudden increase in fundal height could indicate hydramnios. D) A fetus in breech position would still have a normal fundal height measurement. Page Ref: 231
The adolescent client reports to the clinic nurse that her period is late, but her home pregnancy test is negative. What should the nurse explain that these findings most likely indicate? A) "This means you are not pregnant." B) "You might be pregnant, but it might be too early for your home test to be accurate." C) "We don't trust home tests. Come to the clinic for a blood test." D) "Most people don't use the tests correctly. Did you read the instructions?"
Answer: B Explanation: A) Although it might be true that she is not pregnant, this is not the best statement because the pregnancy might be too early for a urine pregnancy test to detect. B) This is a true statement. Most home pregnancy tests have low false-positive rates, but the false-negative rate is slightly higher. Repeating the test in a week is recommended. C) This statement is not worded therapeutically. A clinic pregnancy test is usually a urine test. D) Although this statement gets at the need to read the instructions for the test, it is not worded therapeutically. Page Ref: 214
Which of the following is important for the development of the central nervous system of the fetus? A) Calcium and phosphorus B) Essential fatty acids C) Iron D) Vitamin D
Answer: B Explanation: A) Calcium and phosphorus are involved in the mineralization of fetal bones and teeth, energy and cell production, and acid-base buffering. B) Essential fatty acids are important for the development of the central nervous system of the fetus. Of particular interest are the omega-3 fatty acids and their derivatives. C) Iron requirements increase during pregnancy because of the growth of the fetus and placenta and the expansion of maternal blood volume. D) Vitamin D is known for its role in the absorption and utilization of calcium and phosphorus in skeletal development. Page Ref: 292
The school nurse is planning a class about nutrition for pregnant teens, several of whom have been diagnosed with iron-deficiency anemia. In order to increase iron absorption, the nurse would encourage the teens to consume more of what beverage? A) Gatorade B) Orange juice C) Milk D) Green tea
Answer: B Explanation: A) Gatorade does not contain vitamin C, which increases iron absorption. B) Vitamin C is found in citrus fruits and juices, and is known to enhance the absorption of iron from meat and non-meat sources. C) Milk does not contain vitamin C, which increases iron absorption. D) Green tea does not contain vitamin C, which increases iron absorption. Page Ref: 293—294
The nurse is preparing to assess the pregnant client's fundal height during a routine prenatal visit. Which nursing action is appropriate in this situation? A) Telling the client not to eat or drink for one hour after the procedure B) Asking the client to empty her bladder prior to the procedure C) Obtaining informed consent for the procedure D) Assessing blood pressure after the procedure
Answer: B Explanation: A) It is not necessary for the client to abstain from eating or drinking for one hour after the procedure. This action might be appropriate for a client who is having a glucose tolerance test, not for one undergoing assessment of fundal height. B) It is appropriate for the nurse to ask the client to empty her bladder prior to assessing fundal height. A full bladder may impact the accuracy of the measurement. C) Informed consent is not needed, as assessing fundal height is not an invasive procedure. D) There is no reason to assess the client's blood pressure after measuring fundal height. Page Ref: 243
The nurse is conducting an initial prenatal appointment for a client who believes she is pregnant. Which is considered a positive sign of pregnancy? A) Linea nigra B) Fetal heartbeat C) Breast tenderness D) Urinary frequency
Answer: B Explanation: A) Linea nigra is a probable, not positive, sign of pregnancy. B) A fetal heartbeat is a positive sign of pregnancy. C) Breast tenderness is a probable, not positive, sign of pregnancy. D) Urinary frequency is a probable, not positive, sign of pregnancy. Page Ref: 217
The nurse receives a phone call from a client who claims she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the client's estimated date of delivery (E D D) be if she is pregnant? A) Nov. 13 B) Jan. 17 C) Jan. 10 D) Dec. 3
Answer: B Explanation: A) Nov. 13 is not correct according to Nagele's rule. B) The due date is Jan. 17. Nagele's rule is to add 7 days to the last menstrual period and subtract 3 months. The last menstrual period is April 10, therefore Jan. 17 is the E D D. C) Jan. 10 is not correct according to Nagele's rule. D) Dec. 3 is not correct according to Nagele's rule. Page Ref: 242
A client who is in the second trimester of pregnancy tells the nurse that she has developed a darkening of the line in the midline of her abdomen from the symphysis pubis to the umbilicus. What other expected changes during pregnancy might she also notice? A) Lightening of the nipples and areolas B) Reddish streaks called striae on her abdomen C) A decrease in hair thickness D) Small purplish dots on her face and arms
Answer: B Explanation: A) Pigmentation of the skin increases in areas already hyperpigmented: areolae, nipples, vulva, perianal area, and linea alba. B) Striae, or stretch marks, are reddish, wavy, depressed streaks that may occur over the abdomen, breasts, and thighs as pregnancy progresses. C) A greater percentage of hair follicles go into the dormant phase, resulting in less hair shedding, which is perceived as thickening of the hair. D) Although bright-red elevations on the skin (vascular spider nevi) are a normal finding, petechiae are not. Page Ref: 208
A client presents to the antepartum clinic with a history of a 20-pound weight loss. Her pregnancy test is positive. She is concerned about gaining the weight back, and asks the nurse if she can remain on her diet. What is the nurse's best response? A) "As long as you supplement your diet with the prenatal vitamin, the amount of weight you gain in pregnancy is not significant." B) "I understand that gaining weight after such an accomplishment might not appeal to you but weight gain during pregnancy is important for proper fetal growth." C) "Dieting during pregnancy is considered child neglect." D) "Excessive weight gain in pregnancy is due to water retention, so weight loss following birth will not be an issue."
Answer: B Explanation: A) Supplementation with vitamins is important, but so is maintaining weight gain within the expected parameters. B) Maternal weight gain is an important factor in fetal growth and in infant birth weight. An adequate weight gain over time indicates an adequate caloric intake. C) Child neglect can apply only after the child has been born. D) Weight gain during pregnancy typically is not water-related. Excess weight gain can be difficult to lose. Page Ref: 288
The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form? A) Where was the father of the baby born? B) Do genetic diseases run in the family of the baby's father? C) What is the name of the baby's father? D) Are you married to the father of the baby?
Answer: B Explanation: A) The father's place of birth is not important information to include about the pregnancy. B) This question has the highest priority because it gets at the physiologic issue of inheritable genetic diseases that might directly impact the baby. C) Although it is helpful for the nurse to know the name of the baby's father to include him in the prenatal care, this is psychosocial information. D) Although the marital status of the client might have cultural significance, this is psychosocial information. Page Ref: 228
Nurses who are interacting with expectant families from a different culture or ethnic group can provide more effective, culturally sensitive nursing care by doing what? A) Recognizing that ultimately it is the family's right to make a woman's healthcare choices. B) Obtaining a medical interpreter of the language the client speaks. C) Evaluating whether the client's healthcare beliefs have any positive consequences for her health. D) Accepting personal biases, attitudes, stereotypes, and prejudices.
Answer: B Explanation: A) The nurse should recognize that ultimately it is the woman's right to make her own healthcare choices. B) The nurse should provide for the services of an interpreter if language barriers exist. C) The nurse should evaluate whether the client's healthcare beliefs have any potential negative consequences for her health. D) The nurse should identify personal biases, attitudes, stereotypes, and prejudices. Page Ref: 223
A client at 16 weeks' gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change? A) "Because of your pregnancy, you're not making enough red blood cells." B) "Because your blood volume has increased, your hematocrit count is lower." C) "This change could indicate a serious problem that might harm your baby." D) "You're not eating enough iron-rich foods like meat."
Answer: B Explanation: A) The pregnancy would not cause a decrease in the production of red blood cells. B) Hemoglobin and hematocrit levels drop in early to mid-pregnancy as a result of pregnancy-associated hemodilution. Because the plasma volume increase (50%) is greater than the erythrocyte increase (25%), the hematocrit decreases slightly. C) This change is referred to as physiologic anemia of pregnancy, and is not harmful to the fetus. D) The decreased hematocrit does not mean that the woman is not eating enough iron-rich foods. It is recommended that an iron supplement during pregnancy of 27 milligrams of iron be taken daily, and iron can be found in most prenatal supplements. Page Ref: 209
A 25-year-old primigravida is at 20 weeks' gestation. The nurse takes her vital signs and notifies the healthcare provider immediately because of which finding? A) Pulse 88/minute B) Rhonchi in both bases C) Temperature 37.4°C (99.3°F) D) Blood pressure 122/78 m m H g
Answer: B Explanation: A) The pulse will increase 10-15 beats/minute during pregnancy, with 60-90 beats/minute being the normal range. B) Any abnormal breath sounds should be reported to the healthcare provider. C) Temperature norms in pregnancy are slightly higher due to fetal metabolism: 36.2-37.6°C (97-99.6°F). D) A blood pressure less than or equal to 120/80 m m H g considered normal. Page Ref: 235
The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings? A) Document the findings on the prenatal chart. B) Have the physician see the client today. C) Instruct the client to avoid direct sunlight. D) Analyze previous thyroid hormone lab results.
Answer: B Explanation: A) While all of these findings should be documented on the prenatal chart, additional action is indicated. B) Mottling of the skin is indicative of possible anemia. These abnormalities must be reported to the healthcare provider immediately. C) Instructing the client to avoid direct sunlight is not necessary; rather, additional action is indicated. D) The thyroid gland increases in size during pregnancy due to hyperplasia. Additional action is indicated. Page Ref: 234
A pregnant teenage client is diagnosed with iron-deficiency anemia. Which nutrient should the nurse encourage her to take to increase iron absorption? A) Vitamin A B) Vitamin C C) Vitamin D D) Vitamin E
Answer: B Explanation: A) While vitamin A is good for the body, it does not promote the absorption of iron. B) Vitamin C is known to enhance the absorption of iron from meat and nonmeat sources. C) While vitamin D is good for the body, it does not promote the absorption of iron. D) While vitamin E is good for the body, it does not promote the absorption of iron. Page Ref: 294
The nurse has received a phone call from a multigravida who is 21 weeks pregnant and has not felt fetal movement yet. What is the best action for the nurse to take? A) Reassure the client that this is a normal finding in multigravidas. B) Suggest that she should feel for movement with her fingertips. C) Schedule an appointment for her with her physician for that same day. D) Tell her gently that her fetus is probably dead.
Answer: C Explanation: A) A lack of fetal movement is unusual at 21 weeks, and should be checked. B) Fetal movement can be actively palpated by the client's physician or a trained examiner, but is unlikely to be self-detected by the mother at this stage. C) Quickening, or the mother's perception of fetal movement, occurs about 18 to 20 weeks after the L M P in a primigravida (a woman who is pregnant for the first time) but may occur as early as 16 weeks in a multigravida (a woman who has been pregnant more than once). D) The fetus may or may not have died after or about the 20th week of pregnancy; however, telling the client that the fetus might have died in utero without confirmation of this fact is nontherapeutic. Page Ref: 214
A pregnant client confides to the nurse that she is eating laundry starch daily. The nurse should assess the client for which of the following? A) Alopecia B) Weight loss C) Iron deficiency anemia D) Fecal impaction
Answer: C Explanation: A) Alopecia, a condition that causes hair loss, is not associated with eating laundry starch. B) Weight gain is related to the client's eating laundry starch. C) Iron deficiency anemia is the most common concern with pica. The ingestion of laundry starch or certain types of clay may contribute to iron deficiency by replacing iron-containing foods from the diet or by interfering with iron absorption. D) Fecal impaction is associated with the eating of clay, not laundry starch. Page Ref: 299
The client in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best? A) "Lack of menses and breast enlargement are presumptive signs of pregnancy." B) "The changes you are describing are definitely indicators that you are pregnant." C) "Lack of menses can be caused by many things. We need to do a pregnancy test." D) "You're probably not pregnant, but we can check it out if you like."
Answer: C Explanation: A) Although a lack of menses and breast enlargement are presumptive signs of pregnancy, the nurse should not state this without explaining that these symptoms also can be caused by other conditions. B) This statement is false because amenorrhea and breast enlargement can be caused by other conditions. C) This is a true statement, and addresses that these changes could be caused by conditions other than pregnancy. D) While lack of menses and breast enlargement might not be caused by pregnancy, they likely are the result of pregnancy, and it is inappropriate for the nurse to suggest the client is not pregnant. Page Ref: 214
The nurse is providing prenatal care to an obese client who asks, "How much weight should I gain during my pregnancy?" Which response by the nurse is appropriate? A) "You should gain 15 to 25 pounds." B) "You should gain 25 to 35 pounds." C) "You should gain 11 to 20 pounds." D) "You should gain 28 to 40 pounds."
Answer: C Explanation: A) An overweight client should gain 15 to 25 pounds during pregnancy. B) A pregnant client who has a normal weight before pregnancy should gain 25 to 35 pounds during pregnancy. C) An obese client who becomes pregnant should gain 11 to 20 pounds during pregnancy. D) An underweight client should gain 28 to 40 pounds during pregnancy. Page Ref: 212
The nurse is listening to the fetal heart tones of a client at 37 weeks' gestation while the client is in a supine position. The client states, "I'm getting lightheaded and dizzy." What is the nurse's best action? A) Assist the client to sit up. B) Remind the client that she needs to lie still to hear the baby. C) Help the client turn onto her left side. D) Check the client's blood pressure.
Answer: C Explanation: A) Having the client sit up will not offer the best and fastest relief. B) Having the client lie still will not improve the situation, and is not therapeutic. C) During pregnancy the enlarging uterus may put pressure on the vena cava when the woman is supine, resulting in supine hypotensive syndrome. This pressure interferes with returning blood flow and produces a marked decrease in blood pressure with accompanying dizziness, pallor, and clamminess, which can be corrected by having the woman lie on her left side. D) The client is hypotensive because she is at the end of pregnancy and lying supine. Checking her blood pressure will not relieve the situation. Page Ref: 209
Screening for gestational diabetes mellitus (GDM) is typically completed between which of the following weeks of gestation? A) 36 and 40 weeks B) Before 20 weeks C) 24 and 28 weeks D) 30 and 34 weeks
Answer: C Explanation: A) Screening for gestational diabetes mellitus (GDM) is not completed between 36 and 40 weeks' gestation. B) Screening for gestational diabetes mellitus (GDM) is not completed before 20 weeks' gestation. C) Screening for gestational diabetes mellitus (GDM) is typically completed between 24 and 28 weeks' gestation. D) Screening for gestational diabetes mellitus (GDM) is not completed between 30 and 34 weeks' gestation. Page Ref: 246
A client who is experiencing her first pregnancy has just completed the initial prenatal examination with a certified nurse-midwife. Which statement indicates that the client needs additional information? A) "Because we heard the baby's heartbeat, I am undoubtedly pregnant." B) "Because I have had a positive pregnancy test, I am undoubtedly pregnant." C) "My last period was 2 months ago, which means I'm 2 months along." D) "The increased size of my uterus means that I am finally pregnant."
Answer: C Explanation: A) Hearing the fetal heart rate is a positive, or diagnostic, change of pregnancy, so this statement would not indicate the need for further teaching. B) A positive pregnancy test is a positive, or diagnostic, indication of pregnancy. This statement would not indicate the need for further teaching. C) Amenorrhea is a subjective, or presumptive, change of pregnancy, and is not a reliable indicator of pregnancy in the early months. This statement requires additional teaching. D) Increased uterine size is an objective, or probable, change of pregnancy. Page Ref: 214
What is the increased vascularization causing the softening of the cervix known as? A) Hegar sign B) Chadwick sign C) Goodell sign D) McDonald sign
Answer: C Explanation: A) Hegar sign is a softening of the isthmus of the uterus. B) Increased vascularization causes blue-purple discoloration of the cervix known as Chadwick sign. C) Increased vascularization causes the softening of the cervix known as Goodell sign. D) McDonald sign is an ease in flexing the body of the uterus against the cervix. Page Ref: 214
During her first months of pregnancy, a client tells the nurse, "It seems like I have to go to the bathroom every 5 minutes." The nurse explains to the client that this is because of which of the following? A) The client probably has a urinary tract infection. B) Bladder capacity increases throughout pregnancy. C) The growing uterus puts pressure on the bladder. D) Some women are very sensitive to body function changes.
Answer: C Explanation: A) Increased frequency of urination in the first trimester of pregnancy does not indicate a urinary tract infection. B) Bladder capacity does not increase throughout pregnancy. C) During the first trimester, the growing uterus puts pressure on the bladder, producing urinary frequency until the second trimester, when the uterus becomes an abdominal organ. Near term, when the presenting part engages in the pelvis, pressure is again exerted on the bladder. D) Sensitivity is not the cause of an increased frequency of urination in the first trimester. Page Ref: 210
In early-pregnancy class, the nurse emphasizes the importance of 8-10 glasses of fluid per day. How many of these should be water? A) 1 to 2 B) 2 to 4 C) 4 to 6 D) 3 to 5
Answer: C Explanation: A) One to two glasses of water is not an adequate intake. B) Two to four glasses of water is not an adequate intake. C) A pregnant woman should consume at least 8 to 12 (8 oz) glasses of fluid each day, of which 4 to 6 glasses should be water. D) Three to five glasses of water is not an adequate intake. Page Ref: 296
What would the nurse include as part of a routine physical assessment for a second-trimester primiparous patient whose prenatal care began in the first trimester and is ongoing? A) Pap smear B) Hepatitis B screening (H Bs A g) C) Fundal height measurement D) Complete blood count
Answer: C Explanation: A) Pap smear is usually done at the initial prenatal appointment. B) Hepatitis B screening is done at the initial prenatal appointment. C) At each prenatal visit, the blood pressure, pulse, and weight are assessed, and the size of the fundus is measured. Fundal height should be increasing with each prenatal visit. D) Complete blood count is done at the initial prenatal appointment. Page Ref: 243
The nurse is assessing a pregnant client who reports nasal stuffiness and congestion. Which term will the nurse use to document this data in the medical record? A) Rales B) Epistaxis C) Rhinitis of pregnancy D) Pregnancy-induced asthma
Answer: C Explanation: A) Rales is not the term the nurse uses to document nasal stuffiness and congestion that occurs during pregnancy. B) Epistaxis is not the term the nurse uses to document nasal stuffiness and congestion that occurs during pregnancy. C) Rhinitis of pregnancy is the term that the nurse will use when documenting nasal stuffiness and congestion that often occurs during pregnancy. D) Pregnancy-induced asthma is not the term the nurse uses to document nasal stuffiness and congestion that occurs during pregnancy. Page Ref: 209
It is 1 week before a pregnant client's due date. The nurse notes on the chart that the client's pulse rate was 74-80 before pregnancy. Today, the client's pulse rate at rest is 90. What action should the nurse should take? A) Chart the findings. B) Notify the physician of tachycardia. C) Prepare the client for an electrocardiogram (E K G). D) Prepare the client for transport to the hospital.
Answer: C Explanation: A) The pulse rate frequently increases during pregnancy, although the amount varies from almost no increase to an increase of 10 to 15 beats per minute. This is a normal response, and does not indicate a need for emergency measures or treatment. B) This pulse rate in a near-term client is not considered to be tachycardia. C) This pulse rate in a near-term client does not indicate a need for emergency measures or treatment. D) This client does not need to go to the hospital. Page Ref: 209
A client with a normal prepregnancy weight asks why she has been told to gain 25-35 pounds during her pregnancy while her underweight friend was told to gain more weight. What should the nurse tell the client the recommended weight gain is during pregnancy? A) 25-35 pounds, regardless of a client's prepregnant weight B) More than 25-35 pounds for an overweight woman C) Up to 40 pounds for an underweight woman D) The same for a normal weight woman as for an overweight woman
Answer: C Explanation: A) The recommended total weight gain during pregnancy for a woman of normal weight before pregnancy is 25 to 35 pounds. B) For women who were overweight before becoming pregnant, the recommended gain is 15 to 25 pounds. C) Prepregnant weight determines the recommended weight gain during pregnancy. Underweight women are advised to gain 28-40 pounds. D) Women of normal weight should gain 25-35 pounds during pregnancy, whereas overweight women should limit their weight gain to 15-25 pounds during pregnancy. Page Ref: 212
If a woman has the pre-existing condition of diabetes, the nurse knows that she would be prone to what high-risk factor when pregnant? A) Vasospasm B) Postpartum hemorrhage C) Episodes of hypoglycemia and hyperglycemia D) Cerebrovascular accident (CVA)
Answer: C Explanation: A) Vasospasm would be a high-risk factor for a client with pre-existing cardiac disease. B) Postpartum hemorrhage would be a high-risk factor for a client with pre-existing hyperthyroidism. C) Episodes of hypoglycemia and hyperglycemia would be a high-risk factor for a client with pre-existing diabetes. D) Cerebrovascular accident (C V A) would be a high-risk factor for a client with pre-existing hypertension. Page Ref: 246—247
The pregnant client cannot tolerate milk or meat. What would the nurse recommend to the client to assist in meeting protein needs? A) Wheat bread and pasta B) Ice cream and peanut butter C) Eggs and tofu D) Beans and potatoes
Answer: C Explanation: A) Wheat bread and pasta are not sources of complete protein. B) Ice cream is a milk by-product, and would not be tolerated by this client. C) The best food choices that are nondairy and complete proteins alone are eggs and tofu. D) Beans and potatoes would not provide the client with adequate protein. Page Ref: 290
The nurse is assessing a newly pregnant client. Which finding does the nurse note as a normal psychosocial adjustment in this client's first trimester? A) An unlisted telephone number B) Reluctance to tell the partner of the pregnancy C) Parental disapproval of the woman's partner D) Ambivalence about the pregnancy
Answer: D Explanation: A) An unlisted telephone number does not indicate psychosocial adjustment. B) Reluctance to tell the partner about the pregnancy might indicate that the client anticipates disapproval, and is not a normal psychosocial adjustment. C) Parental disapproval of the client's partner does not indicate psychosocial adjustment. D) Ambivalence toward a pregnancy is a common psychosocial adjustment in early pregnancy. Page Ref: 240
The primigravida at 22 weeks' gestation has a fundal height palpated slightly below the umbilicus. Which of the following statements would best describe to the client why she needs to be seen by a physician today? A) "Your baby is growing too much and getting too big." B) "Your uterus might have an abnormal shape." C) "The position of your baby can't be felt." D) "Your baby might not be growing enough."
Answer: D Explanation: A) At 22 weeks' gestation, the fundal height should be at about 22 c m. B) Uterine shape can be assessed only with diagnostic imaging techniques such as ultrasound or C T scan. C) The position of the baby is not noted until 36 weeks' gestation. D) The fundal height at 20-22 weeks should be about even with the umbilicus. At 22 weeks' gestation, a fundal height below the umbilicus and a uterine size that is inconsistent with length of gestation could indicate fetal demise. Page Ref: 243
The nurse is teaching a pregnant client the clinical manifestations associated with preterm labor. Which client statement indicates the need for further education? A) "Menstrual-like cramps are a sign of preterm labor." B) "A dull low backache is a sign of preterm labor." C) "Diarrhea is a sign of preterm labor." D) "Vomiting is a sign of preterm labor."
Answer: D Explanation: A) Painful menstrual-like cramps are a sign of preterm labor. This statement indicates appropriate understanding of the information presented. B) A dull low backache is a sign of preterm labor. This statement indicates appropriate understanding of the information presented. C) Diarrhea is a sign of preterm labor. This statement indicates appropriate understanding of the information presented. D) Vomiting is not a clinical manifestation associated with preterm labor. This statement indicates the need for further education. Page Ref: 248
A woman calls the clinic and tells a nurse that she thinks she might be pregnant. She wants to use a home pregnancy test before going to the clinic, and asks the nurse how to use it correctly. What information should the nurse give? A) The false-positive rate of these tests is quite high. B) If the results are negative, the woman should repeat the test in 2 weeks if she has not started her menstrual period. C) A negative result merely indicates growing trophoblastic tissue and not necessarily a uterine pregnancy. D) The client should follow up with a healthcare provider after taking the home pregnancy test.
Answer: D Explanation: A) The false-positive rate of these tests is quite low. B) If the results are negative, the woman should repeat the test in 1 week if she has not started her menstrual period. C) A positive result merely indicates growing trophoblastic tissue and not necessarily a uterine pregnancy. D) It is important that clients remember that the tests are not always accurate and they should follow up with a healthcare provider. Page Ref: 216—217
The nurse is providing care to a client who is entering the second trimester of pregnancy. Which client statement does the nurse anticipate when assessing this client? A) "We picked out a name for a boy and for a girl." B) "We bought the baby's crib and car seat this past weekend." C) "I am so uncomfortable all the time and I can't seem to sleep at night." D) "I am angry with my husband for not showing more interest in my pregnancy."
Answer: D Explanation: A) The nurse would expect this client statement during the third, not second, trimester of pregnancy. B) The nurse would expect this client statement during the third, not second, trimester of pregnancy. C) The nurse would expect this client statement during the third, not second, trimester of pregnancy. D) The nurse would expect this statement during the second trimester of pregnancy. Page Ref: 218
The nurse is assessing a pregnant client during a scheduled prenatal visit who reports dizziness and clamminess when lying in bed each morning. Which statement by the nurse is appropriate based on this data? A) "The doctor may order an amniocentesis to determine if the fetus is healthy." B) "This information indicates that you are developing gestational hypertension." C) "Be sure to sit up slowly and stay sitting for several minutes prior to getting up." D) "Try lying on your left side to enhance blood flow, which will help your symptoms."
Answer: D Explanation: A) This data does not warrant an amniocentesis. B) This data does not support the diagnosis of gestational hypertension. C) This statement is appropriate for a client who is experiencing orthostatic hypotension and is not appropriate for the data assessed. D) The data suggests that the client is experiencing supine hypotension, which is often corrected by having the client lie on her left side. Page Ref: 209
