Chapter 11, Nursing Care Related to Assessment of a Pregnant Family

A patient at 6 weeks' gestation asks if she can listen to the fetal heart sounds. The nurse informs the patient that fetal heart sounds cannot be heard with a Doppler until when? 8 weeks 10 to 12 weeks 18 to 20 weeks 24 weeks

10 to 12 weeks

A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every: 4 weeks. 3 weeks. 2 weeks. 1 week.

4 weeks

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of spontaneous abortion (miscarriage) within the first trimester. The nurse is correct to document the history as: G = 4, T = 2, P = 0, A = 0, L = 1 G = 3, T = 1, P = 0, A = 1, L = 1 G = 1, T = 1, P = 1, A = 0, L = 1 G = 2, T = 0, P = 0, A = 0, L = 1

G = 3, T = 1, P = 0, A = 1, L = 1

A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history? G3 P0020 G2 P0020 G2 P1020 G3 P0021

G3 P0020

Charlene McCoy, who has several children already, reports for a first prenatal visit. She seems preoccupied and withdrawn, and she makes consistently negative remarks about the pregnancy. Reviewing her records, you note that she is receiving a serotonin reuptake inhibitor. What should you do? Reassure her that ambivalence is normal Refer her for drug and alcohol counseling Give her printed material to read at home Alert the RN or primary care provider

alert the RN or primary care provider

A client at 16 weeks' gestation is scheduled for prenatal testing. Which of the following would the nurse anticipate as the most likely screening test for congenital anomalies based on the current age of this pregnancy? Cardiocentesis. Amniocentesis. Nuchal translucency testing. Chorionic villi sampling.

amniocentesis

The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure? contraction stress test amniocentesis nonstress test biophysical profile

amniocentesis

The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best? "By this time, the fundus should drop down lower because the baby is moving towards the pelvic inlet." "At 36 weeks' gestation, the fundus is in the normal expected location." "To be honest, the fundus should be lower since you have gained minimal weight." "Just get prepared, the fundus might actually get a little higher until a few days before you go into labor."

at 36 weeks gestation the fundus is in the normal expected location

A nurse at the health care facility assesses a client at 20 weeks' gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client? at the top of the symphysis pubis halfway between the symphysis pubis and the umbilicus at the level of the umbilicus at the xiphoid process

at the level of the umbilicus

A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location? symphysis pubis between the symphysis and umbilicus at the umbilicus just below the ensiform cartilage

at the umbilicus

Why is the first prenatal visit usually the longest prenatal visit? Laboratory tests are performed. Baseline data is collected. A pelvic exam with Papanicolaou test is performed. Extensive client teaching is done.

baseline data is collected

A client at 10 weeks' gestation is complaining of ptyalism over the past 2 weeks. What intervention would the nurse recommend to this client? Select all that apply. Chew gum. Use saline nasal spray. Wear a panty liner. Eat a large, protein rich meal in the evening. Suck on hard candies.

chew gum suck on hard candies

The nurse is providing care for a pregnant client who has been given the necessary requisitions for laboratory work by the primary care provider. The client notices that the lab tests include testing for HIV and other sexually transmitted infections, and expresses alarm, stating, "I don't understand why the doctor would suspect that I've got these diseases." What is the nurse's most therapeutic statement? "Unfortunately, these infections have the potential to harm the fetus. It's important that the doctor identifies them early in your pregnancy." "Every pregnant client is tested for these diseases; it doesn't necessarily suggest that the doctor suspects that you have them." "Pregnancy is a major change, so every member of the care team makes sure that your health is assessed carefully." "Sexually transmitted infections are much more common than most people believe."

every pregnant client is tested for these diseases it doesn't necessarily suggest that the doctor suspects that you have them

A nurse is providing care to a pregnant woman. To promote optimal outcomes, the nurse would engage in which activity? Select all that apply. Individualized assessment Assistance with social coordination Counseling Authoritarian decision making Teaching

individualized assessment counseling teaching

An adolescent at 8 weeks' gestation is at her first prenatal visit. During the health history interview, the nurse asks the client, "Are you afraid of anyone?" What is the nurse assessing with this question? mood mental status intimate partner violence social history

intimate partner violence

The nurse is conducting an assessment of a pregnant client at a routine second trimester prenatal visit. Which lower extremity assessment should the nurse prioritize? Lateral movement of the kneecap Presence of varicosities Diameter of the calf muscle Blanching and refilling of toenails

presence of varicosities

A pregnant client at 18 weeks' gestation has arrived for her routine prenatal visit. Which assessment findings should the nurse prepare to document at this time? Select all that apply. Fundal height of approximately 18 cm Quickening Insomnia Braxton Hicks contractions Leg cramps

quickening fundal height of approximately 18 cm

The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage? All activities that the client does in a prepregnant state Relaxing activities such as hot baths and jacuzzis High-impact movements enabling less time in the activity Stretching and breathing exercises such as yoga

stretching and breathing exercises such as yoga

A gravid woman who is in her first trimester reports experiencing constipation. Which statement by the client indicates the need for further instruction? "Increasing my water intake will aid in reducing my constipation." "Taking gentle enemas no more frequently than once a week is acceptable." "Adding more vegetables to my diet will be helpful." "Exercise such as walking daily helps increase my bowel movements."

taking gentle enemas no more frequently than once a week is acceptable

A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next? Have the primary health care provider see the client. Tell the client these are normal findings during pregnancy. Ask the client if there is a family history of arthritis. Document these findings in the client's chart.

tell the client these are normal findings during pregnancy

At 24 weeks' gestation a client is asked to drink a sweet orange solution and then wait an hour to have blood drawn. The client asks if this is the test to determine if she has diabetes. What is the best response by the nurse? "This is a screening procedure. If your result is elevated you will be scheduled for a longer test to determine if you have gestational diabetes." "This is a diagnostic test to identify insulin resistance during pregnancy." "Yes. If the results of your blood work are elevated you have gestational diabetes and will be started on insulin." "No, this is part of the routine prenatal lab work. The test for gestational diabetes will be done during your third trimester."

this is a screening procedure if your result is elevated you will be scheduled for a longer test to determine if you have gestational diabetes

A nurse is obtaining a health history and social profile from a newly pregnant patient and asks the patient about physical activity. The nurse specifically investigates if the patient goes hiking or camping. The nurse asks about these activities primarily for which reason? To determine if the patient is active To assess the patient's risk for Lyme disease To evaluate the patient's potential for exposure to shingles To better understand the patient's likes and dislikes

to assess the patients risk for lyme disease

A woman has a positive pregnancy test and comes to the nurse with left lower quadrant pain. Bimanual examination reveals a tender mass. Which of the following is suspected? Threatened abortion Appendicitis Ovarian cyst Tubal pregnancy

tubal pregnancy

The nursing instructor is explaining the nursing care that is given to a client during her pregnancy. The instructor determines the session is successful when the students correctly choose which method will be used to evaluate the effectiveness of the nursing care they will provide? Ask the client to respond to a preprinted survey about nursing care. Interview the client on her first postpartum visit about the nursing care she have received. Identify the nursing diagnoses for the specific client. Verify that desired outcomes for identified goals have been met.

verify that desired outcomes for identified goals have been met

The nurse is conducting a prenatal class for a group of primigravida clients. Which instruction will the nurse prioritize when teaching about breast care? Use hot water and a mild soap to keep the nipples clean. Wash the nipples with a deodorant soap to keep them clean and help toughen them. Use an antibacterial soap and cool water to keep the nipples clean. Wash the nipples with clean water only.

wash the nipples with clean water only

The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting? Return right away. Watch it and report if heavy increase in bleeding. The bleeding, called Chadwick sign, is a normal part of pregnancy. The cervical mucus plug may have been expelled.

watch it and report if heavy increase in bleeding

The nurse assesses a 20-week gestational client at a routine prenatal visit. What will the nurse predict the fundal height to be on this client experiencing an uneventful pregnancy? 24 cm 12 cm 16 cm 20 cm

20 cm

A primigravida client has presented for her first prenatal visit and is concerned about the potential weight gain and the struggle to lose the weight after the baby's birth. How much weight should the nurse recommend this client with a normal BMI gain during her pregnancy to ensure a healthy fetus? 15 to 20 lbs 20 to 25 lbs 30 to 35 lbs 10 to 15 lbs

30 to 35 lbs

A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply. Establish a baseline of present health. Determine the gestational age of the fetus. Monitor for fetal development and maternal well-being. Maximize the risk of possible complications. Identify women at risk for complications. Increase the business of the clinic.

Establish a baseline of present health. Determine the gestational age of the fetus. Monitor for fetal development and maternal well-being. Identify women at risk for complications.

The nurse is documenting a non-pregnant client's obstetric history. The client informed the nurse she has 4 children living at home. She birthed one child at 34 weeks' gestation, one child at 37 weeks' gestation, one at 38 weeks' gestation, and one at 39 weeks' gestation. The client has had one abortion. Using the GTPAL format, how will the nurse document the client's obstetric history? G5, T2, P1, A1, L3 G4, T3, P0, A1, L3 G5, T2, P2, A1, L4 G4, T3, P1, A1, L4

G5, T2, P2, A1, L4

How should the nurse record the obstetric history for a newly pregnant client who previously delivered two live infants at term and had one abortion at 12 weeks' gestation? Gravida 3, para 2 Gravida 3, para 3 Gravida 4, para 2 Gravida 4, para 3

Gravida 4, para 2

The health care provider is concerned about a client's fetus having appropriate blood flow through the fetal vessels. Which diagnostic test does the nurse anticipate to confirm a diagnosis? Transabdominal ultrasound Doppler study Amniocentesis Maternal serum alpha-fetoprotein screening

doppler study

Which information is most important in order to decrease the risk of complications if the client decides to work until her due date? Eat light meals Frequent rest periods Adequate sleep Flat shoes

frequent rest periods

The parents of a neonate born at 32 weeks' gestation ask about the purpose of the surfactant being given to the baby. What is the best response by the nurse? Promotes clearing mucus from the respiratory tract Assists with ciliary body maturation in the upper airways Helps the lungs remain expanded after the initiation of breathing Helps maintain a rhythmic breathing pattern

helps the lungs remain expandedafter the initation of breathing

The nurse is caring for a neonate whose mother received no medical care for either of her pregnancies. When assessing the neonate's status, which would indicate a potential A, B, and O incompatibility? Hypothyroidism Hemolytic anemia Electrolyte deficiencies Abnormal bleeding

hemolytic anemia

The nurse is assessing a client at 14 weeks' gestation at a routine prenatal visit and notes the fundal height is at the umbilicus. The nurse will most likely interpret this finding to indicate which situation? Intrauterine growth retardation Multiple fetal pregnancy Deficient amniotic fluid Urinary retention

multiple fetal pregnancy

The nurse is advising a pregnant woman during her first prenatal visit regarding the frequency of future visits. Which schedule is recommended for prenatal care? once every 3 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth once every 4 weeks for the first 28 weeks, then every 3 weeks until 36 weeks, and then every 2 weeks until the birth once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth once every 4 weeks for the first 36 weeks, then weekly until the birth

once every 4 weeks for the first 28 weeks then every 2 weeks until 36 weeks and then weekly until the birth

The nurse performs a nonstress test (NST) on a client at 36 weeks' gestation. What criteria does the nurse look for on the tracing to determine that the NST is reactive? Presence of 2 accelerations in 20 minutes Presence of 2 decelerations in 60 minutes Presence of 2 accelerations per hour Presence of 2 contractions during a 20 minute window

presence of 2 accelerations in 20 minutes

Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? Split S1S2 Premature ventricular contractions S4 (atrial gallop) Soft systolic murmur

soft systolic murmur