Exam 2 Maternity

This excessive vomiting during pregnancy will often result in which of the following?

Electrolyte imbalance

9. A client states has significant pregnancy induce nausea and vomiting. She has been unable to drink or keep down food for several days. She denies voiding in several hours. Which intervention would the nurse complete first?

Establish an intravenous access device

The client returns in one month for follow-up appointment in repeat labs. What conclusion does the nurse makes about the treatment?

Fetal growth pattern is appropriate Serum glucose levels is appropriate Dietary exercise regimen seems to be working

10. A client who is 6 months pregnant explains her exercise regime. Which statement reflects a cause for a concern in the nurse?

I find it hard to talk when I am at the end of my run

A pregnant client wishes to know if sexual intercourse would be safe during pregnancy. Which should the nurse confirm before educating the client regarding sexual behavior during pregnancy?

*Client does not have cervical insufficiency. Client does not have an incompetent cervix. The nurse should inform the client that sexual activity is permissible during pregnancy unless there is a history of incompetent cervix, vaginal bleeding, placenta previa, risk of preterm labor, multiple gestation, premature rupture of membranes, or presence of any infection. Anemia and facial and hand edema would be contraindications to exercising but not intercourse. Freedom from anxieties and worries contributes to adequate sleep promotion.

A client with preeclampsia is receiving magnesium sulfate and oxytocin IV during an induction of labor at 39 weeks. What does the explain in the main indication of magnesium sulfate?

A 21 year old client 6 weeks pregnant is diagnosed with hyperemesis gravidarum

11. A nurse is caring for a client. Which client should the nurse assess first?

A client with gestational diabetes who states she has a headache is shaky and doesn't feel well

Which neonate is at highest risk for developing neonatal herpes following birth?

A newborn who was a vaginal delivery to a mother who had her initial outbreak during the third trimester of pregnancy and has active lesions

A pregnant woman has a rubella titer drawn on her first prenatal visit. The nurse explains that this test measures: A. platelet level. B. Rh status. C. immunity to German measles. D. red blood cell count.

Answer: C Rationale: A rubella titer detects antibodies for the virus that causes German measles. If the titer is 1:8 or less, the woman is not immune and requires immunization after birth. Platelet level and red blood cell count would be determined by a complete blood count. Rh status would be determined by blood typing.

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A. +2 station. B. 0 station. C. -2 station. D. crowning.

Answer: C Rationale: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

5. A client is pregnant and has a BMI of 32.5. which health issue is a focus for the nurse during the assessment? Select 4 that apply A. Determine glucose tolerance B. Assess for hypertension in sequential readings C. Monitor for deep venous thrombosis D. Assess for risk of postpartum depression E. Screen for substance use and abuse F. Assess for signs and sources of infection

A. Determine glucose tolerance B. Assess for hypertension in sequential readings C. Monitor for deep venous thrombosis D. Assess for risk of postpartum depression

Which action is a priority when caring for a woman during the fourth stage of labor? A. assessing the uterine fundus B. offering fluids as indicated C. encouraging the woman to void D. assisting with perineal care

Answer: A Rationale: During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

A couple comes to the clinic for preconception counseling and care. As part of the visit, the nurse teaches the couple about fertilization and initial development, stating that the zygote formed by the union of the ovum and sperm consists of how many chromosomes? A. 22 B. 23 C. 44 D. 46

Answer: D Rationale: With fertilization, the ovum, containing 23 chromosomes, and the sperm, containing 23 chromosomes, join, forming a zygote with a diploid number or 46 chromosomes.

A V-shape is visible what action is needed next?

Change maternal position side to side

8. A nurse cares for a client who is rh negative who undergoes amniocentesis. Which intervention does the nurse anticipates?

Injection of RhoD immunoglobulin.

A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition?

Cytomegalovirus

The client takes the 3-hour glucose tolerance test and receives the diagnosis of gestational diabetes. The nurse begins to develop a plan of care. What additional assessment data should the nurse obtain? Select all that apply

Economic ability to purchase healthy food Physical activity patterns Access to supermarkets with fresh food

Why is it important to preform prenatal testing?

Maternal serum alpha-fetoprotein at the appropriate gestation age of the client To avoid a false positive results

Exam 1 A nurse cares for a client in an active labor. The client is a survivor of sexual abuse. Prior to vaginal exam, what would be the most appropriate response by the nurse?

May I touch you now?

The nurse cares for client in active labor, while repositioning the client, she states "I think my water just broke". Which intervention should the nurse implement first?

Reposition the ultrasound transducer and assess fetal heart rate

The prepares an infusion of oxytocin to augment labor for client in labor. Based on information from the medication administration record, how will the nurse set the infusion control device for the prescribe initial rate?

Round to the nearest whole number

A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess?

Severe "knife-like" abdominal pain with vaginal bleeding

The nurse is caring for a client at 26-weeks gestation in the outpatient clinic. A 44-year old female identified at birth, occupation computer programmer. G3T2P0. The nurse implemented a dietary plan to manage the client's diabetes during pregnancy. Which three elements should the nurse include in the dietary teaching plan? Choose 3 only

Should consume 3 small moderate meals 4 snacks a day Identify carbohydrates with low glycemic index recommend consultation with a registered dietitian

7. The client is pregnant and has bipolar disorder. She asked the nurse about the safety of taking lithium during breast feeding. Which would be the appropriate response by the nurse?

perhaps you can discuss the safety of the drug with your health care provider

Case study A nurse is caring for a client admitted into the labor and delivery unit at 35 weeks gestation and preeclampsia...indicated or not indicated

Stop magnesium infusion- indicated Administering calcium gluconate- indicated Place client in supine position- not indicated Activate rapid response - indicated Provide oxygen- indicated Monitoring fetus- indicated Administering antiseizure medication - not indicated Draw serum magnesium levels- indicated Check for medical errors - indicated Elevated extremities- not indicated

While on the examining table a multigravida client who is 19 weeks pregnant tells the nurse that she feels the baby moving. Which action should the nurse take?

Tell the client that fetal movement is normal

A couple is seeking an fertility counseling, the provider has identified the factors listed below in the woman's health history. Which of these findings will be contributed to the couple's infertility?

The client is 38 years old

12. A client enters a prenatal clinic after reviewing the client's electronic health record. Which information would be of concern with the pregnancy? ( Nurse thin 38.00)

The genetic implications of sickle cell anemia

A healthy 30-year-old woman with a normal weight explains to the nurse that she does not know the type in the amount of food she should eat now that she is pregnant.

The nurse explains to her she will add approximately 300 calories per day to her diet

4. The nurse cares for a 37-year-old client gradvida5para4 at 37 weeks gestation. The client is admitted with placenta previa. which priority assessment does the nurse implement in the plan of care. you click to specify whether each assessment if priority, not necessary, and contraindicated.

Vital signs- Priority Frequency and duration of contractions- Priority Point of care blood glucose- not necessary Electronic fetal monitoring- Priority Weight of paranal pads- Priority Client's pain rating- Not necessary Cervical effacement and dilation- contraindicated

During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as: A. Hegar sign. B. Goodell sign. C. Chadwick sign. D. Ortolani sign.

Answer: A Rationale: Hegar sign refers to the softening of the lower uterine segment or isthmus. Bluish coloration of the cervix is termed Chadwick sign. Goodell sign refers to the softening of the cervix. Ortolani sign is a maneuver done to identify developmental dysplasia of the hip in infants

A primigravida client has been pushing for 2 hours when the head emerges. The fetus fails to deliver. Which should be a nurse's interpretation of this information? A) cephalopelvic disproportion B) shoulder dystocia C) persistent occiput posterior position D) cord prolapse

A) cephalopelvic disproportion

A nurse is assessing a pregnant woman and suspects that the woman may be experiencing pica. To help support this suspicion, the nurse evaluates the woman for signs and symptoms of which condition? A. Iron-deficiency anemia B. Urinary tract infection C. Diarrhea D. Heartburn

Answer: A Rationale: Three main substances consumed by women with pica are soil or clay (geophagia), ice (pagophagia), and laundry starch (amylophagia). Because each of these can lead to iron deficiency anemia, the nurse should evaluate the client for the condition. Urinary tract infection, diarrhea, and heartburn are not associated with pica.

When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because: A. these measurements may not change until after the blood loss is large. B. the body's compensatory mechanisms activate and prevent any changes. C. they relate more to change in condition than to the amount of blood lost. D. maternal anxiety adversely affects these vital signs.

Answer: A

A nurse is caring for several women in labor. The nurse determines that which woman is the latent phase of labor? A. contractions every 5 minutes, cervical dilation 3 cm B. contractions every 3 minutes, cervical dilation 6 cm C. contractions every 2 1/2 minutes, cervical dilation 8 cm D. contractions every 1 minute, cervical dilation 9 cm

Answer: A Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent phase. Contractions every 3 minutes with cervical dilation of 6 cm, contractions every 2½ minutes with cervical dilation of 8 cm, and contractions every 1 minute with cervical dilation of 9 cm suggest the active phase of labor.

A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion? A. Ultrasound B. Amniocentesis C. Human chorionic gonadotropin (hCG) level D. Triple marker screening

Answer: A Rationale: A client experiencing an intrauterine fetal demise (IUFD) is likely to seek care when she notices that the fetus is not moving or when she experiences contractions, loss of fluid, or vaginal bleeding. History and physical examination frequently are of limited value in the diagnosis of fetal death, since many times the only history tends to be recent absence of fetal movement and no fetal heart beat heard. An inability to obtain fetal heart sounds on examination suggests fetal demise, but an ultrasound is necessary to confirm the absence of fetal cardiac activity. Once fetal demise is confirmed, induction of labor or expectant management is offered to the client. An amniocentesis, hCG level, or triple marker screening would not be used to confirm IUFD.

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? A. infection B. hemorrhage C. trauma D. hypovolemia

Answer: A Rationale: Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid, so bacteria can ascend.

A woman in her second trimester comes to the clinic for a routine follow-up visit. The woman's prepregnancy blood pressure was 112/70 mm Hg. On this visit, the woman's blood pressure is 104/64 mm Hg. The nurse would interpret this finding as suggestive of which event? A. A normal pregnancy finding secondary to progesterone effects B. Indication that the woman is experiencing orthostatic hypotension C. Signal that the woman is developing gestational hypertension D. Sign that the woman is anemic

Answer: A Rationale: Blood pressure, especially the diastolic pressure, declines slightly during pregnancy as a result of peripheral vasodilation caused by progesterone. It usually reaches a low point mid pregnancy and thereafter increases to prepregnancy levels until term. During the first trimester, blood pressure typically remains at the prepregnancy level. During the second trimester, the blood pressure decreases 5 to 10 mm Hg and thereafter returns to first-trimester levels. This decrease in blood pressure begins at about 7 weeks' gestation and persists until 32 weeks' gestation, when it begins to rise to prepregnancy levels. The client's blood pressure suggests a normal finding related to peripheral vasodilation from progesterone. Any significant rise in blood pressure during pregnancy should be investigated to rule out gestational hypertension. Gestational hypertension is a clinical diagnosis defined by the new onset of hypertension (systolic of 140 mm Hg or higher and/or diastolic of 90 mm Hg or higher) after 20 weeks' gestation. A lower blood pressure does not suggest anemia. Orthostatic hypotension occurs when the blood pressure drops more than 20 mm Hg systolic or 10 mm Hg diastolic with a change in position, such as going from a lying to a standing position.

A pregnant woman undergoes a triple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's estriol and alpha-fetoprotein levels are decreased with high hCG levels? A. Down syndrome B. sickle-cell anemia C. cardiac defects D. respiratory disorders

Answer: A Rationale: Decreased levels might indicate Down syndrome or trisomy 18. Sickle cell anemia may be identified by chorionic villus sampling. Levels would be increased with cardiac defects, such as tetralogy of Fallot. It does not detect respiratory disorders.

During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A. "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B. "Since this is your first pregnancy, you can estimate it will be about 10 hours." C. "It will depend on how big the baby is when you go into labor." D. "Time isn't important; your health and the baby's health are key."

Answer: A Rationale: It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last. There is no way to estimate the likely strength and frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the complex fetal rotations needed for an efficient labor will take place properly. All of these factors are unknowns when a woman starts labor. Telling the woman an approximate time would be inappropriate because there is no way to determine the length of labor. It is highly individualized. Although fetal size and maternal and fetal health are important considerations, these responses do not address the woman's concern.

A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver? A. Fetal presentation B. Fetal position C. Fetal attitude D. Fetal flexion

Answer: A Rationale: Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. The first maneuver determines presentation; the second maneuver determines position; the third maneuver confirms presentation by feeling for the presenting part; the fourth maneuver determines attitude based on whether the fetal head is flexed and engaged in the pelvis.

Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding? A. linea nigra B. striae gravidarum (stretch marks) C. melasma (chloasma) D. vascular spiders

Answer: A Rationale: Linea nigra refers to the darkened line of pigmentation down the middle of the abdomen in pregnant women. Striae gravidarum refers to stretch marks, irregular reddish streaks on the abdomen, breasts, and buttocks. Melasma (chloasma) refers to the increased pigmentation on the face, also known as the "mask of pregnancy." Vascular spiders are small, spiderlike blood vessels that appear usually above the waist and on the neck, thorax, face, and arms.

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? A. respiratory depression B. urinary retention C. abdominal distention D. hyperreflexia

Answer: A Rationale: Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? A. delusional beliefs B. feelings of anxiety C. sadness D. insomnia

Answer: A Rationale: Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? A. Document the finding, as it is a normal finding at this time. B. Contact the primary care provider, as it indicates early DIC. C. Contact the primary care provider, as it is a first sign of postpartum eclampsia. D. Obtain a prescription for a CBC, as it suggests postpartum anemia.

Answer: A Rationale: Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia.

A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband." The woman's pregnancy has been uneventful. The nurse responds based on the understanding that: A. it is safe to have intercourse at this time. B. intercourse at this time is likely to cause rupture of membranes. C. there are other ways that the couple can satisfy their needs. D. intercourse at this time is likely to result in premature labor.

Answer: A Rationale: Sexual activity is permissible during pregnancy unless there is a history of vaginal bleeding, placenta previa, risk of preterm labor, multiple gestation, incompetent cervix, premature rupture of membranes, or presence of infection. Rupture of membranes or premature labor is unlikely since the woman's pregnancy has been uneventful so far. Alternative sexual positions may be necessary as the woman's abdomen increases in size.

A biophysical profile has been completed on a pregnant woman. The nurse interprets which score as normal? A. 9 B. 7 C. 5 D. 3

Answer: A Rationale: The biophysical profile is a scored test with five components, each worth 2 points if present. A total score of 10 is possible if the NST is used. Overall, a score of 8 to 10 is considered normal if the amniotic fluid volume is adequate. A score of 6 or below is suspicious, possibly indicating a compromised fetus; further investigation of fetal well-being is needed.

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? A. hematoma B. laceration C. bladder distention D. uterine atony

Answer: A Rationale: The woman most likely has a hematoma based on the findings: firm uterus with bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area; severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony would be noted by a uncontracted uterus.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? A. Check the fetal heart rate. B. Perform a vaginal exam. C. Notify the primary care provider immediately. D. Change the linen saver pad.

Answer: A Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply. A. cervical dilation of 6 cm B. contractions every 2 to 3 minutes C. cervical effacement of 30% D. contractions every 90 seconds E. strong desire to push

Answer: A, B Rationale: During the active phase, the cervix usually dilates from 6 to 10 cm, with 40% to 100% effacement taking place. Contractions become more frequent, occurring every 2-5 min and increase in duration (45 to 60 seconds). Effacement of 30% reflects the latent phase. Contractions occurring every 90 seconds suggest the second stage of labor. A strong urge to push reflects the later perineal phase of the second stage of labor.

A nurse is conducting an in-service program for a group of labor and birth unit nurses about cesarean birth. The group demonstrates understanding of the information when they identify which conditions as appropriate indications? Select all that apply. A. active genital herpes infection B. placenta previa C. previous cesarean birth D. prolonged labor E. fetal distress

Answer: A, B, C, E Rationale: The leading indications for cesarean birth are previous cesarean birth, breech presentation, dystocia, and fetal distress. Examples of specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or placental abruption), previous classic uterine incision or scar, gestational hypertension, diabetes, positive human immunodeficiency virus (HIV) status, and dystocia. Fetal indications include malpresentation (nonvertex presentation), congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress.

A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply. A. nifedipine B. magnesium sulfate C. dinoprostone D. misoprostol E. indomethacin

Answer: A, B, E Rationale: Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and nifedipine (a calcium channel blocker). These drugs are used "off label": this means they are effective for this purpose but have not been officially tested and developed for this purpose by the FDA. Dinoprostone and misoprostol are used to ripen the cervix.

Which characteristics about amniotic fluid would alert the prenatal nurse to further investigate? Select all that apply. A. Oligohydramnios is noted on assessment. B. The amount of amniotic fluid fluctuates at each checkup. C. Polyhydramnios is noted on assessment. D. The client has approximately 2 L of amniotic fluid at term. E. The client has approximately 1 L of amniotic fluid at term.

Answer: A, C, D Rationale: Amniotic fluid surrounds the embryo and increases in volume as the pregnancy progresses, reaching approximately 1 L at term. Its volume changes constantly as the fetus swallows and voids. Oligohydramnios is too little amniotic fluid (500 mL at term) and is associated with uteroplacental insufficiency, fetal renal abnormalities, and a higher risk of surgical births and low birth weight infants. Too much amniotic fluid (2,000 mL at term), termed polyhydramnios, is associated with maternal diabetes, neural tube defects, chromosomal deviations, and malformations of the central nervous system and/or gastrointestinal tract that prevent normal swallowing of amniotic fluid by the fetus.

A nurse is assessing a pregnant woman on a routine checkup. When assessing the woman's gastrointestinal tract, what would the nurse expect to find? Select all that apply. A. hyperemic gums B. increased peristalsis C. reports of bloating D. heartburn E. nausea

Answer: A, C, D, E Rationale: Gastrointestinal system changes include hyperemic gums due to estrogen and increased proliferation of blood vessels and circulation to the mouth; slowed peristalsis; acid indigestion and heartburn; bloating and nausea and vomiting.

A woman visits the prenatal clinic and is noted to have oligohydramnios. The client asks, "Why is this fluid important anyway?" Which statements would be included in the nurse's response? Select all that apply. A. "Amniotic fluid helps maintain your baby's body temperature." B. "The fetus ingests amniotic fluid for its nourishment." C. "Too little amniotic fluid is linked with placental problems." D. "Amniotic fluid keeps your baby free from any teratogens." E. "It acts like a cushion protecting your baby from trauma that may occur."

Answer: A, C, E Rationale: Sufficient amounts of amniotic fluid help maintain a constant body temperature for the fetus and cushion the fetus from trauma. Oligohydramnios is associated with placental problems. The fetus does ingest amniotic fluid but not for nourishment. Amniotic fluid does not protect the fetus from teratogens.

A 24-year-old client who is planning to become pregnant comes to the clinic for an evaluation. When assessing the client, which finding would alert the nurse to implement measures to reduce the client's risk for problems during pregnancy? Select all that apply. A. drinks wine 3 to 4 times/week B. quit smoking 4 years ago C. follows a vegetarian diet D. has a BMI of 22 E. uses ibuprofen daily

Answer: A, E Rationale: The use of alcohol and prescription and over-the-counter drugs can be harmful to a growing fetus. Thus the nurse would need to address these areas with the client. If the client was still smoking, then that too would need to be addressed. Healthy nutrition is important, but being a vegetarian does not necessarily indicate that the client is a nutritional risk. A BMI of 22 is considered normal and would not pose a problem.

Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of which condition? A. maternal diabetes B. placental insufficiency C. neural tube defects D. fetal gastrointestinal malformations

Answer: B Rationale: A deficiency of amniotic fluid, oligohydramnios, is associated with uteroplacental insufficiency and fetal renal abnormalities. Excess amniotic fluid is associated with maternal diabetes, neural tube defects, and malformations of the gastrointestinal tract and central nervous system.

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? A. administering broad-spectrum antibiotics B. inspecting the placenta after delivery for intactness C. manually removing the placenta at birth D. applying pressure to the umbilical cord to remove the placenta

Answer: B Rationale: After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: A. normal. B. a possible infection. C. meconium passage. D. transient fetal hypoxia.

Answer: B Rationale: Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. respiratory rate of 16 breaths per minute B. 1+ deep tendon reflexes C. urine output of 45 mL/hour D. alert level of consciousness

Answer: B Rationale: Diminished deep tendon reflexes (1+) suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.

A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching? A. introducing solid foods immediately to increase sleep cycle B. demonstrating comfort measures to quiet a crying infant C. encouraging daily outings to the shopping mall with the newborn D. allowing the infant to cry for at least an hour before picking him or her up

Answer: B Rationale: Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and stimulation would be more appropriate.

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected? A. two fingerbreadths above the umbilicus B. at the level of the umbilicus C. two fingerbreadths below the umbilicus D. four fingerbreadths below the umbilicus

Answer: B Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus. Over the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? A. extent of opening to its widest diameter B. degree of thinning C. passage of the mucous plug D. fetal presenting part

Answer: B Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event has most likely occurred? A. cervical dilation B. lightening C. bloody show D. Braxton Hicks contractions

Answer: B Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor. Braxton Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.

A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago. Which finding would the nurse expect? A. bright red discharge B. pinkish brown discharge C. deep red mucus-like discharge D. creamy white discharge

Answer: B Rationale: Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A. presence of lochia serosa B. frequent scant voidings C. fundus firm, below umbilicus D. milk filling in both breasts

Answer: B Rationale: Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

The nurse is teaching a couple about X-linked disorders because they are concerned that they might pass on hemophilia to their children. Which response indicates the need for further teaching? A. "The father can't be a carrier if he doesn't have hemophilia." B. "If the father doesn't have it, then his kids won't either." C. "If the mother is a carrier, her daughter could be one too." D. "If the mother is a carrier, her sons will have hemophilia."

Answer: B Rationale: Males are more affected than females. A male has only one X chromosome, and all the genes on his X chromosome will be expressed whereas a female will usually need both X chromosomes to carry the disease. There is no male-to-male transmission (since no X chromosome from the male is transmitted to male offspring), but any man who is affected will have carrier daughters. If a woman is a carrier, there is a 50% chance that her sons will be affected and a 50% chance that her daughters will be carriers.

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? A. nonpalpable fundus B. moderate lochia serosa C. bruising on arms and legs D. fever

Answer: B Rationale: Subinvolution is usually identified at the woman's postpartum examination 4 to 6 weeks after birth. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would suggest a coagulopathy. Fever would suggest an infection.

A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? A. Apply warm soaks to the area. B. Notify the health care provider. C. Massage the uterine fundus. D. Encourage the client to void.

Answer: B Rationale: The client is experiencing postpartum hemorrhage secondary to a perineal hematoma. The nurse needs to notify the health care provider about these findings to prevent further hemorrhage. Applying warm soaks to the area would do nothing to control the bleeding. With a perineal hematoma, the uterus is firm, so massaging the uterus or encouraging the client to void would not be appropriate.

A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which possible effect would the nurse include? A. ankle edema B. urinary frequency C. backache D. hemorrhoids

Answer: B Rationale: The client is in her first trimester and would most likely experience urinary frequency as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids would be more common during the later stages of pregnancy.

A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A. determines that the procedure is effective. B. helps support the lower uterine segment. C. aids in expressing accumulated clots. D. prevents uterine muscle fatigue.

Answer: B Rationale: The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The hand, usually the dominant hand that is placed on the fundus, helps to determine uterine firmness (and thus the effectiveness of the massage). Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the uterus leads to muscle fatigue.

When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage? A. Regular contractions B. Cervical dilation C. Fetal movement through the birth canal D. Placental separation

Answer: B Rationale: The primary change occurring during the first stage of labor is progressive cervical dilation. Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh positive newborn based on the understanding that this drug will prevent her from: A. becoming Rh positive. B. developing Rh sensitivity. C. developing AB antigens in her blood. D. becoming pregnant with an Rh-positive fetus.

Answer: B Rationale: The woman who is Rh-negative and whose infant is Rh-positive should be given Rho(D) immune globulin within 72 hours after birth to prevent sensitization.

After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement? A. "I should notice a decrease in abdominal cramping during breast-feeding." B. "I should wash my hands before starting to breastfeed." C. "The baby can be awake or sleepy when I start to feed him." D. "The baby's mouth will open up once I put him to my breast."

Answer: B Rationale: To promote successful breastfeeding, the mother should wash her hands before breast feeding and make sure that the baby is awake and alert and showing hunger signs. In addition, the mother should lightly tickle the infant's upper lip with her nipple to stimulate the infant to open the mouth wide and then bring the infant rapidly to the breast with a wide-open mouth. The mother also needs to know that her afterpains will increase during breastfeeding.

A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? A. "I will use a soft toothbrush to brush my teeth." B. "I can take ibuprofen if I have any pain." C. "I need to avoid drinking any alcohol." D. "I will call my health care provider if my stools are black and tarry."

Answer: B Rationale: Individuals receiving anticoagulant therapy need to avoid use of any over-the-counter products containing aspirin or aspirin-like derivatives such as NSAIDs (ibuprofen) to reduce the risk for bleeding. Using a soft toothbrush and avoiding alcohol are appropriate measures to reduce the risk for bleeding. Black, tarry stools should be reported to the health care provider.

The nurse reviews the medical record of a woman who has come to the clinic for an evaluation. The client has a history of mitral valve prolapse and is listed as risk class II. During the visit, the woman states, "We want to have a baby, but I know I am at higher risk. But what is my risk, really?" Which response by the nurse would be appropriate? A. "If you do get pregnant, you will need to be seen by a cardiologist every other month for monitoring." B. "Your risk during pregnancy is small, but you should see your cardiologist first before getting pregnant." C. "Your heart disease would put too much strain on your heart if you were to get pregnant." D. "Your pregnancy would be uneventful, but you would need specialized care for labor and birth."

Answer: B Rationale: Typically, a woman with class I or II cardiac disease can go through a pregnancy without major complications. For class I disease, there is no detectable increased risk of maternal mortality and no increase or a mild increase in morbidity. For class II disease, there is a small increased risk of maternal mortality or moderate increase in morbidity and cardiac consultation should occur every trimester. It is best to have the woman see her cardiologist before becoming pregnant. A woman with class III disease needs frequent visits with the cardiac care team throughout pregnancy. There is a significantly increased risk of maternal mortality or severe morbidity and cardiologist consult should occur every other month with prenatal care and delivery occurring at an appropriate level hospital. A woman with class IV disease is typically advised to avoid pregnancy.

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A. "Holding a pillow against my incision will help me when I cough." B. "I'm going to have to wait a few days before I can start breastfeeding." C. "I guess the nurses will be getting me up and out of bed rather quickly." D. "I'll probably have a tube in my bladder for about 24 hours or so."

Answer: B Rationale: Typically, breastfeeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.

During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. Which nursing diagnosis would be the priority for this client? A. Ineffective tissue perfusion related to supine hypotensive syndrome B. Impaired gas exchange related to pulmonary congestion C. Activity intolerance related to increased metabolic requirements D. Anxiety related to fear of pregnancy outcome

Answer: B Rationale: Typically, heart rate increases by approximately 10 to 15 beats per minute during pregnancy and the lungs should be clear. Dyspnea may occur during the third trimester as the enlarging uterus presses on the diaphragm. However, the findings described indicate that the woman is experiencing impaired gas exchange. There is no evidence to support supine hypotensive syndrome, increased metabolism, or anxiety.

A pregnant woman comes to the clinic and tells the nurse that she has been having a whitish vaginal discharge. The nurse suspects vulvovaginal candidiasis based on which assessment finding? A. fever B. vaginal itching C. urinary frequency D. incontinence

Answer: B Rationale: Vaginal secretions become more acidic, white, and thick during pregnancy. Most women experience an increase in a whitish vaginal discharge, called leukorrhea. This is normal except when it is accompanied by itching and irritation, possibly suggesting Candida albicans, a monilial vaginitis, which is a very common occurrence in this glycogen-rich environment. Fever would suggest a more serious infection. Urinary frequency occurs commonly in the first trimester, disappears during the second trimester, and reappears during the third trimester. Incontinence would not be associated with a vulvovaginal candidiasis. Incontinence would require additional evaluation.

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration? A. early decelerations B. variable decelerations C. prolonged decelerations D. late decelerations

Answer: B Rationale: Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns. Early decelerations are visually apparent, usually symmetrical and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes

A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? A. "Call us back when you start having contractions." B. "Come to the clinic or emergency department for an evaluation." C. "Drink 3 to 4 glasses of water and lie down." D. "Come in as soon as you feel the urge to push."

Answer: B Rationale: When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

At a prenatal class, the participants ask the nurse who would benefit from genetic counseling. Which responses by the nurse are correct? Select all that apply. A. "A woman who is a grand multigravida." B. "A woman whose husband is age 50 years or older." C. "A woman who has been exposed to teratogens." D. "A young teenager experiencing her first pregnancy." E. "A woman who receives an abnormal alpha-fetoprotein result."

Answer: B, C, E Rationale: Those shown to benefit from genetic counseling are women over the maternal age 35 years or older when the baby is born; couples where the paternal age is 50 years or older; when a pregnancy screening abnormality is noted, including the alpha-fetoprotein. Genetic screening is encouraged where there has been teratogen exposure or risk. Teenage pregnancies or having multiple pregnancies do not qualify for genetic counselling unless the above risks have been identified.

At a prenatal class, the participants ask the nurse who would benefit from genetic counseling. Which responses by the nurse are correct? Select all that apply. A. "A woman who is a grand multigravida." B. "A woman whose husband is age 50 years or older." C. "A woman who has been exposed to teratogens." D. "A young teenager experiencing her first pregnancy." E. "A woman who receives an abnormal alpha-fetoprotein result."

Answer: B, C, E Rationale: Those shown to benefit from genetic counseling are women over the maternal age 35 years or older when the baby is born; couples where the paternal age is 50 years or older; when a pregnancy screening abnormality is noted, including the alpha-fetoprotein. Genetic screening is encouraged where there has been teratogen exposure or risk. Teenage pregnancies or having multiple pregnancies do not qualify for genetic counselling unless the above risks have been identified.

A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is having contractions sporadically. Which instructions would be most appropriate for the nurse to give the woman? Select all that apply. A. "Walk around the house for the next half hour." B. "Drink two or three glasses of water." C. "Lie down on your back." D. "Try emptying your bladder." E. "Stop what you are doing and rest."

Answer: B, D, E Rationale: Appropriate instructions for the woman who may be experiencing preterm labor include having the client stop what she is doing and rest for an hour, empty her bladder, lie down on her left side, and drink two to three glasses of water.

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. A. current pregnancy history B. fundal height measurement C. support system D. estimated date of birth E. membrane status F. contraction pattern

Answer: B, E, F Rationale: As part of the admission physical assessment, the nurse would assess fundal height, membrane status, and contractions. Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A. intense B. strong C. moderate D. mild

Answer: C Rationale: A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong or intense contraction feels like the forehead.

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? A. prophylactic heparin administration B. compression stockings C. early ambulation D. warm compresses

Answer: C Rationale: Although compression stockings and prophylactic heparin administration may be appropriate, the most cost-effective preventive method is early ambulation. It is also the easiest method. Warm compresses are used to treat superficial venous thrombosis.

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? A. Offer warm blankets. B. Encourage the woman to void. C. Apply an ice pack to the site. D. Offer a warm sitz bath.

Answer: C Rationale: An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

A nurse is working with a pregnant client to schedule follow-up visits for the pregnancy. Which statement by the client indicates that she understands the scheduling? A. "I need to make visits every 2 months until I am 36 weeks' pregnant." B. "Once I get to 28 weeks' pregnant, I have to come twice a month." C. "From now until I am 28 weeks' pregnant, I will be coming once a month." D. "I will make sure to get a day off every 2 weeks to make my visits."

Answer: C Rationale: Continuous prenatal care is important for a successful pregnancy outcome. The recommended follow-up visit schedule for a healthy pregnant woman is as follows: every 4 weeks up to 28 weeks' (7 months') gestation; every 2 weeks from 29 to 36 weeks' gestation; every week from 37 weeks' gestation to birth.

A nurse is conducting a class for a group of pregnant women in their first trimester about the emotional responses that occur during pregnancy. Which response would the nurse identify as being seen commonly during the second trimester? A. Introversion B. Ambivalence C. Acceptance D. Emotional balance

Answer: C Rationale: During the second trimester, the physical changes of pregnancy, including an enlarging abdomen and fetal movement, bring a sense of reality and validity to the pregnancy leading to acceptance. Ambivalence, or having conflicting feelings at the same time, is a universal feeling and is considered normal when preparing for a lifestyle change and new role. Pregnant women commonly experience ambivalence during the first trimester. Usually ambivalence evolves into acceptance by the second trimester, when fetal movement is felt. Introversion seems to heighten during the first and third trimesters, when the woman's focus is on behaviors that will ensure a safe and health pregnancy outcome. Emotional lability, not emotional balance, is characteristic throughout most pregnancies. One moment a woman can feel great joy, and within a short time, she can feel shock and disbelief. It is not more common during one trimester or another.

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A. "I'm feeling contractions mostly in my back." B. "My contractions are about 6 minutes apart and regular." C. "The contractions slow down when I walk around." D. "If I try to talk to my partner during a contraction, I can't."

Answer: C Rationale: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A. -2 B. -1 C. 0 D. +1

Answer: C Rationale: Fetal engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A. sedatives B. tocolytics C. uterine stimulants D. corticosteroids

Answer: C Rationale: For hypotonic labor, a uterine stimulant such as oxytocin may be prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? A. "Express some milk from your breasts every so often to relieve the distention." B. "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C. "Apply ice packs to your breasts to reduce the amount of milk being produced." D. "Take several warm showers daily to stimulate the milk let-down reflex."

Answer: C Rationale: For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breastfeeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching? A. "I should take my iron with milk." B. "I should avoid drinking orange juice." C. "I need to eat foods high in fiber." D. "I'll call the primary care provider if my stool is black and tarry."

Answer: C Rationale: Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her primary care provider.

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A. butorphanol B. fentanyl C. naloxone D. promethazine

Answer: C Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A. multiparity, age of mother, operative birth B. size of placenta, small baby, operative birth C. uterine atony, placenta previa, operative procedures D. prematurity, infection, length of labor

Answer: C Rationale: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

A client at a prenatal class requests information on how the gender of a baby is determined. Which statement made by the nurse would be most accurate? A. "Gender is determined by week 20 of gestation and depends on whether the ovum is fertilized by a Y-bearing or an X-bearing sperm." B. "Gender is determined as the embryo is fertilized by a Y-bearing or an X-bearing sperm." C. "Gender is determined at conception and depends on whether the ovum is fertilized by a Y bearing or an X-bearing sperm." D. "Gender is determined at conception and depends on whether the sperm is fertilized by a Y bearing or X-bearing ovum."

Answer: C Rationale: Sex determination is also determined at fertilization and depends on whether the ovum is fertilized by a Y-bearing sperm or an X-bearing sperm. Approximately half of sperm carry the XX chromosome and the other half carries XY. An XX zygote will become a female, and an XY zygote will become a male. That is why it is scientifically correct to say that the sex of the infant is determined by the father and not by the mother. Gender is determined before the embryo stage and at conception by sperm carrying Y- or X-bearing chromosomes.

Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A. -2 B. -1 C. 0 D. +1

Answer: C Rationale: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations.

A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest? A. "Limit your intake of fluids." B. "Eliminate salt from your diet." C. "Try elevating your legs when you sit." D. "Wear spandex-type full-length pants."

Answer: C Rationale: The client is experiencing dependent edema due to the effect of gravity and increased capillary permeability caused by elevated hormone levels and increased blood volume and accompanied by sodium and water retention. The best suggestion would be to encourage the woman to elevate her legs when sitting to promote venous return and minimize the effects of gravity. Neither fluids nor salt should be limited or eliminated. Six to eight glasses of water each day are necessary to replace fluids lost through perspiration. Foods high in sodium should be avoided. Spandex-type full-length pants would be constricting and interfere with venous return.

When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? A. reciprocity B. engrossment C. bonding D. attachment

Answer: C Rationale: The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

Which method would be most effective in evaluating the parents' understanding about their newborn's care? A. Demonstrate all infant care procedures. B. Allow the parents to state the steps of the care. C. Observe the parents performing the procedures. D. Routinely assess the newborn for cleanliness.

Answer: C Rationale: The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental roles develop and grow through interaction with their newborn. The nurse would involve both parents in the newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for cleanliness would provide little information about parental learning.

A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A. supine B. lithotomy C. upright D. knee-chest

Answer: C Rationale: The use of any upright position helps to reduce the length of labor. Research shows that women who assumed the upright position during the first stage of labor experienced significant improvement in the progress of labor, faster fetal head descent, significant reduction of pain, and a good Apgar score. Additionally, studies show that recumbent positions result in supine hypotension, diminishing uterine activity and reducing the dimensions of the pelvic outlet. The knee-chest position would assist in rotating the fetus in a posterior position.

A woman is at 20 weeks' gestation. The nurse would expect to find the fundus at which area? A. just above the symphysis pubis B. midway between the pubis and umbilicus C. at the level of the umbilicus D. midway between the umbilicus and xiphoid process

Answer: C Rationale: The uterus, which starts as a pear-shaped organ, becomes ovoid as length increases over width. By 20 weeks' gestation, the fundus, or top of the uterus, is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy

A nurse measures a pregnant woman's fundal height and finds it to be 28 cm. The nurse interprets this to indicate that the client is at how many weeks' gestation? A. 14 weeks' gestation B. 20 weeks' gestation C. 28 weeks' gestation D. 36 weeks' gestation

Answer: C Rationale: Typically, the height of the fundus is measured when the uterus arises out of the pelvis to evaluate fetal growth. At 12 weeks' gestation the fundus can be palpated at the symphysis pubis. At 16 weeks' gestation the fundus is midway between the symphysis and the umbilicus. At 20 weeks the fundus can be palpated at the umbilicus and measures approximately 20 cm from the symphysis pubis. By 36 weeks the fundus is just below the xiphoid process and measures approximately 36 cm.

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A. lochia rubra with a fleshy odor B. respiratory rate of 16 breaths per minute C. temperature of 101° F (38.3° C) D. pain rating of 2 on a scale from 0 to 10

Answer: C Rationale: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 100.4º F (38º C), during the first 24 hours. A temperature above 100.4º F (38º C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding.

A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? A. asphyxia B. clavicular fracture C. cephalhematoma D. central nervous system injury

Answer: C Rationale: Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.

A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at 39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation. Using the GTPAL method, the nurse would document her obstetric history as: A. 3 2 1 0 3. B. 3 1 2 2 3. C. 4 1 1 1 3. D. 4 2 1 3 1.

Answer: C Rationale: Using the GTPAL method, the woman's history would be documented as 4 (her fourth pregnancy), 1 (number of term pregnancies), 1 (number of pregnancies ending in preterm birth), 1 (number of pregnancies ending before 20 weeks or viability), and 3 (number of living children).

A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect? A. amniotic fluid embolism B. shoulder dystocia C. uterine rupture D. umbilical cord prolapse

Answer: C Rationale: Uterine rupture is associated with crack cocaine use disorder. Generally, the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A. greater than after a vaginal birth. B. about the same as after a vaginal birth. C. less than after a vaginal birth. D. saturated with clots and mucus.

Answer: C Rationale: Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

Which change in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy? A. ligament tightening B. decreased swayback C. increased lordosis D. joint contraction

Answer: C Rationale: With pregnancy, the woman's center of gravity shifts forward, requiring a realignment of the spinal curvatures. There is an increase in the normal lumbosacral curve (lordosis). Ligaments of the sacroiliac joints and pubis symphysis soften and stretch. Increased swayback and an upper spine extension to compensate for the enlarging abdomen occur. Joint relaxation and increased mobility occur due to the influence of the hormones relaxin and progesterone.

During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. This occurs about 4 or 5 times during the testing period. The nurse interprets this as: A. variable decelerations. B. fetal tachycardia. C. a nonreactive pattern. D. reactive pattern.

Answer: D Rationale: A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm.

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A. posterior position B. firm C. closed D. shortened

Answer: D Rationale: A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.

A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A. shapeless B. circular. C. triangular. D. slit-like.

Answer: D Rationale: After birth, the external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

A client comes to the prenatal clinic for her first visit. When determining the client's estimated due date, the nurse understands what which method is the most accurate? A. Nagele's rule B. gestational wheel C. birth calculator D. ultrasound

Answer: D Rationale: Although there are several methods for determining the EDD, the ultrasound is considered the most accurate method for dating the pregnancy.

A nurse is assessing a pregnant woman in her last trimester. Which question would be most appropriate to use to gather information about weight gain and fluid retention? A. "What's your usual dietary intake for a typical week?" B. "What size maternity clothes are you wearing now?" C. "How puffy does your face look by the end of a day?" D. "How swollen do your ankles appear before you go to bed?

Answer: D Rationale: Edema, especially in the dependent areas such as the legs and feet, occurs throughout the day due to gravity. It improves after a night's sleep. Therefore, questioning the client about ankle swelling would provide the most valuable information. Asking about her usual dietary intake would be valuable in assessing complaints of heartburn and indigestion. The size of maternity clothing may provide information about weight gain but would have little significance for fluid retention. Swelling in the face may suggest preeclampsia, especially if it is accompanied by dizziness, blurred vision, headaches, upper quadrant pain, or nausea.

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which factor would the nurse identify as being a significant contributor to this condition? A. early ambulation B. short duration of labor C. breastfeeding D. use of anesthetics

Answer: D Rationale: Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breastfeeding, and early ambulation.

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman makes which statement? A. "I'll sit down to rest for 30 minutes." B. "I'll try to move my bowels." C. "I'll lie down with my legs raised." D. "I'll drink several glasses of water."

Answer: D Rationale: If the woman experiences any signs and symptoms of preterm labor, she should stop what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three glasses of water, feel her abdomen and note the hardness of the contraction, and call her health care provider and describe the contraction.

A nurse is describing the various birth methods to pregnant couples. Which information would the nurse include as part of the Lamaze method? A. focus on the pleasurable sensations of birth B. concentration on sensations while turning on to own bodies C. interruption of the fear-tension-pain cycle D. use of specific breathing and relaxation techniques

Answer: D Rationale: Lamaze is a psychoprophylactic ("mind prevention") method of preparing for labor and birth that promotes the use of specific breathing and relaxation techniques. The Bradley method emphasizes the pleasurable sensations of birth, teaching women to concentrate on these sensations while "turning on" to their own bodies. The Dick-Read method seeks to interrupt the circular pattern of fear, tension, and pain during the labor and birthing process.

A nurse is providing education to a woman who is experiencing postpartum hemorrhage and is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the woman identifies which drug as possibly being prescribed as treatment? A. oxytocin B. methylergonovine C. carboprost D. magnesium sulfate

Answer: D Rationale: Magnesium sulfate is during labor as a tocolytic agent to slow or halt preterm labor. It is not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? A. an inverted nipple on the affected breast B. no breast milk in the affected breast C. an ecchymotic area on the affected breast D. hardening of an area in the affected breast

Answer: D Rationale: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.

When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed? A. hemoglobin and hematocrit B. urine for culture C. fetal ultrasound D. fundal height measurement

Answer: D Rationale: On every follow-up visit, fundal height measurements are performed to evaluate fetal growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be done on the initial visit and then repeated if the woman's status indicates a need for doing so. Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal period, but it is not done at every visit.

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? A. prolactin B. estrogen C. progesterone D. oxytocin

Answer: D Rationale: Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.

As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn? A. in the first week B. within the first 2 weeks C. in approximately 1 month D. within the first 6 weeks

Answer: D Rationale: PPD usually has a gradual onset and becomes evident within the first 6 weeks postpartum. Postpartum blues typically manifests in the first week postpartum. Postpartum psychosis usually appears about 3 months after birth of the newborn.

The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse determines that the women understood the description when they identify the condition as postpartum: A. depression. B. psychosis. C. bipolar disorder. D. blues.

Answer: D Rationale: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with birth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A. supine B. side-lying C. sitting D. knee-chest

Answer: D Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? A. leg pain on ambulation with mild ankle edema B. calf pain with dorsiflexion of the foot C. perineal pain with swelling along the episiotomy D. sharp, stabbing chest pain with shortness of breath

Answer: D Rationale: Sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent.

A nurse is reviewing the results of four clients who have undergone amniocentesis. Which client would the nurse recommend that the health care provider see first? A. client at 16 weeks' gestation with placenta previa and high alpha-fetoprotein level B. client at 34 weeks' gestation with gestational diabetes and L/S ratio of 2:1 C. client at 36 weeks' gestation with preeclampsia and amniotic fluid negative for bilirubin D. client at 38 weeks' gestation with fetal heart rate of 110 and green amniotic fluid sample

Answer: D Rationale: The client at 38 weeks' gestation should be evaluated first because the green amniotic fluid suggests possible meconium staining and the fetal heart rate is bradycardic. Immediate evaluation and intervention would be essential. A high alpha fetoprotein level may suggest a neural tube defect or possible chromosomal abnormality. Although important to address, this client would not be the priority. The client at 34 weeks' with gestational diabetes and an L/S ratio of 2:1 indicates that the lung of the fetus are mature, should delivery be necessary. Amniotic fluid that is negative for bilirubin is a normal finding.

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A. "Your uterus is still shrinking in size; that's why you're feeling this pain." B. "Let me check your vaginal discharge just to make sure everything is fine." C. "Your body is responding to the events of labor, just like after a tough workout." D. "The baby's sucking releases a hormone that causes the uterus to contract."

Answer: D Rationale: The woman is describing afterpains, which are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breastfeeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time? A. at 32 weeks' gestation and immediately before discharge B. 24 hours before birth and 24 hours after birth C. in the first trimester and within 2 hours of birth D. at 28 weeks' gestation and again within 72 hours after birth

Answer: D Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.

The nurse is determining the risk associated with post term pregnancy as part of a in serve presentation. The nurse determines that more teaching is needed when the group identifies which factor as in underlying reason for problems in the fetus?

Increase amniotic fluid value.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vagina exam. Which I the following actions should the nurse take?

Observe for crowning

A client presents to labor and delivery at 32 weeks gestation with preterm premature rupture membranes. Which complication should the nurse prepare for?

Preterm delivery

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description? A. scant B. light C. moderate D. large

Rationale: The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

RhoGAM is given to Rh-negative women to prevent maternal sensitization. In addition to pregnancy, Rh-negative women would also receive this medication after which of the following? a. Therapeutic or spontaneous abortion b. Head injury from a car accident c. Blood transfusion after a hemorrhage d. Unsuccessful artificial insemination procedure

Therapeutic or spontaneous abortion

A nurse is performing an assessment on a new client. The woman estimates that she is approximately 16 weeks pregnant. While assessing her, the nurse asks her about apparent scratch marks on her hands, and she tells the nurse that she has three cats at home. What screening would be prescribed for this woman? A. toxoplasmosis B. cytomegalovirus C. herpes simplex virus D. hepatitis C

Toxoplasmosis

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Uteroplacental insufficiency

A pregnant woman is diagnosed with abruptio placentae. When reviewing the woman's medical record, which of the following would the nurse expect to find? a) Bright red vaginal bleeding b) Fetal heart rate within normal range c) Firm, rigid uterus on palpation d) Absence of pain

c) Firm, rigid uterus on palpation Rationale: The uterus is firm to rigid to the touch with abruptio placentae; it is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. Bright red vaginal bleeding is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

During a prenatal visit, a health care provider decides to admit a client to the hospital. Based on the nurse's admission note below, which complication of pregnancy would the health care provider suspect? a) Placenta previa b) Iron deficiency anemia c) Hyperemesis gravidarum d) Pregnancy-induced hypertension

c) Hyperemesis gravidarum

3. When managing health care for pregnant women at a prenatal clinic, the nurse should recognize that the most significant barrier to access to care is the pregnant woman's: a. Age. b. Minority status. c. Educational level. d. Inability to pay.

d. Inability to pay. The most significant barrier to health care access is the inability to pay for services. This is compounded by the fact that many physicians refuse to care for women who cannot pay.

Which fetal presentation would be indicated for a c-section birth?

fetus is at breech position

The nurse assesses fetal heart rate pattern for a client who is in active labor, the baseline fetal heart rate is 140 bpm, but drops to 100 bpm.

intermittently 15 seconds and returns to baseline within 30 seconds.

6. A patient is prescribed the biophysical profile and asked about the purpose of this test the nurse provides the instruction. Which statement by the client indicates and accurate understanding of the instruction?

this assessment makes sure my fetus is doing okay and it is healthy