Maternal Exam 1 Review
A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727)
0504 Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format.
A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? A) "Ambivalent feelings are quite common for women early in pregnancy." B) "Perhaps you should see a counselor to discuss these feelings further." C) "Have you spoken to your mother about these feelings?" D) "Don't worry. You will be fine once the baby is born."
A) "Ambivalent feelings are quite common for women early in pregnancy." This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy.
A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching? A) "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." B) "The sex of the baby is determined by week 8 of pregnancy." C) "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy." D) "You will first feel your baby move in week 24 of pregnancy."
A) "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation.
A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? A) "This infection is treated with one dose of azithromycin." B) "If your sexual partner has no symptoms, no medication is needed." C) "You have to avoid sexual relations for 3 days." D) "You need to return in 6 months for retesting."
A) "This infection is treated with one dose of azithromycin." A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.
A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? A) 4-0-1-2-2 B) 3-0-2-0-2 C) 2-0-0-2-0 D) 4-2-0-2-2
A) 4-0-1-2-2 This response correctly describes the client's current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L).
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? A) Cervical dilation B) Report of pain above the umbilicus C) Brownish vaginal discharge D) Amniotic fluid in the vaginal vault
A) Cervical dilation Cervical dilation and effacement are indications of true labor.
A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy? A) Gradual lordosis B) Increased abdominal muscle tone C) Posterior neck flexion D) Decreased mobility of pelvic joints
A) Gradual lordosis Clients who are pregnant can develop a gradual, forward curving of the spine as the growth of the fetus pulls the pelvis forward. This lordosis resolves after delivery.
A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? A)"This is a presumptive sign of pregnancy." B)"This is a probable sign of pregnancy." C)"This is a possible sign of pregnancy." D)"This is a positive sign of pregnancy."
A)"This is a presumptive sign of pregnancy." Presumptive signs of pregnancy include physical changes that are apparent to the client, such as quickening.
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? A)The presenting part is 1 cm above the ischial spines. B) The presenting part is 1 cm below the ischial spines. C) The cervix is 1 cm dilated. D) The cervix is effaced 1 cm.
A)The presenting part is 1 cm above the ischial spines. Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.
Nurses Notes Client is a 20-year-old primigravida who is at 18 weeks of gestation. Client reports increased nausea and vomiting within the past week and decreased appetite. Client denies abdominal or epigastric pain. Current weight 58 kg (128 lb). Client's weight 2 weeks ago was 60.8 kg (134 lb). Vital Signs: Temperature: 37° C (98.6° F) Heart rate: 110/min Respiratory rate: 20/min Blood pressure: 100/70 mm Hg Oxygen saturation: 96% Diagnostic Results Hemoglobin: 11.0 g/dL (12 to 16 g/dL) Hematocrit: 30% (37 to 47%) BUN: 28 mg/dL (10 to 20 mg/dL) Sodium: 124 mEq/L (136 to 145 mEq/L) Magnesium: 1.29 mEq/L (1.33 to 2.1 mEq/L) Chloride: 94 mEq/L (98 to 106 mEq/L) Calcium: 8.6 mg/dL (9 to 10.5 mg/dL) Total Bilirubin: 1.2 mg/dL (0.3-1 mg/dL)
Actions to Take: Initiate IV fluid therapy Administer metoclopramide Potential Condition: Hyperemesis gravidarum Parameters to monitor: Intake & output Weight
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? A) "Exercising during pregnancy is not recommended." B) "Daily jogging for up to 30 minutes is fine throughout the pregnancy." C) "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." D) "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."
B) "Daily jogging for up to 30 minutes is fine throughout the pregnancy." While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods.
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? A) Administer oxygen via nasal cannula. B) Assist the client to breathe into a paper bag. C) Have the client tuck her chin to her chest. D) Instruct the client to increase her respiratory rate to more than 42 breaths per min.
B) Assist the client to breathe into a paper bag. This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? A) Rupture of the membranes B) Changes in the cervix C) Station of the presenting part D) Pattern of contractions
B) Changes in the cervix Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? A) 3 cm above the umbilicus B) Slightly above the umbilicus C) Slightly below the umbilicus D) 3 cm below the umbilicus
B) Slightly above the umbilicus At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation.
A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A) "This will occur during the last trimester of pregnancy." B) "This will happen by the end of the first trimester of pregnancy." C) "This will occur between the fourth and fifth months of pregnancy." D) "This will happen once the uterus begins to rise out of the pelvis."
C) "This will occur between the fourth and fifth months of pregnancy." Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks.
A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? A) "You should not receive the rubella vaccine while breastfeeding." B) "You should receive a varicella vaccine before you deliver." C) "You can receive an influenza vaccination during pregnancy." D) "You cannot receive the Tdap vaccine until after you deliver."
C) "You can receive an influenza vaccination during pregnancy." It is recommended that pregnant women receive annual influenza vaccinations.
A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? A) Vertex B) Shoulder C) Breech D) Mentum
C) Breech An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? A) Limit alcohol consumption. B) Increase intake of iron-rich foods. C) Consume foods fortified with folic acid. D) Avoid foods containing aspartame.
C) Consume foods fortified with folic acid. Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus.
A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? A) Contractions that last for 60 seconds each with a 4-min rest between contractions B) A contraction that lasts 4 min followed by a period of relaxation C) Contractions that last for 60 seconds each with a 3-min rest between contractions D) Contractions that last 45 seconds each with a 3-min rest between contractions
C) Contractions that last for 60 seconds each with a 3-min rest between contractions A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? A) Assist the client into a comfortable position. B) Observe the perineum for signs of crowning. C) Have the client pant during the next contractions. D) Help the client to the bathroom to void.
C) Have the client pant during the next contractions. Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.
A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply.) A) Eczema B) Psoriasis C) Linea nigra D) Chloasma E) Striae gravidarum
C) Linea nigra D) Chloasma E) Striae gravidarum Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy.
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? A) Administer prescribed analgesic medication. B) Encourage the client to rest between contractions. C) Massage the client's back. D) Turn the client onto her left side.
C) Massage the client's back. The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client's back focuses on neuromuscular and cognitive changes.
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 vaginal examination. Which of the following actions should the nurse take? A) Apply fundal pressure. B) Observe for the presence of a nuchal cord. C) Observe for crowning. D) Prepare to administer oxytocin.
C) Observe for crowning. In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.
A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? A) "I should drink about 2 liters of fluid each day." B) "I should not drink alcoholic beverages during my pregnancy." C) "I can have a moderate amount of caffeine daily." D) "I should increase my calcium intake to 1,500 milligrams per day"
D) "I should increase my calcium intake to 1,500 milligrams per day" A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching? A) "You will need to increase your calcium intake during breast feeding." B) "Prenatal vitamins will meet your need for increased vitamin D during pregnancy." C) "Vitamin E requirements decline during pregnancy due to the increase in body fat." D) "You will need to double your intake of iron during pregnancy."
D) "You will need to double your intake of iron during pregnancy." During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client's red blood cell volume.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? A) Prepare for a cesarean birth. B) Assist the client to an upright position. C) Prepare for an immediate vaginal delivery. D) Assist the client to turn onto her side.
D) Assist the client to turn onto her side. Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.
A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? A) Leukorrhea B) Urinary frequency C) Nausea and vomiting D) Facial edema
D) Facial edema Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? A) Fetal attitude is in general flexion. B) Fetal lie is longitudinal. C) Maternal pelvis is gynecoid. D) Fetal position is persistent occiput posterior.
D) Fetal position is persistent occiput posterior. The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief.
A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.) A) History of migraines B) Nulliparous C) Twin gestations D) History of gestational hypertension E) Oligohydramnios
History of migraines is correct. History of migraines is a risk factor for hyperemesis gravidarum, which typically occurs during the first 20 weeks of pregnancy. Nulliparous is correct. Hyperemesis gravidarum is more common in nulliparous women, beginning in the first trimester. Clinical manifestations can continue throughout the pregnancy in some women. Twin gestations is correct. Twin gestations are a risk factor for hyperemesis gravidarum and might be related to increasing hormone levels of estrogen, progesterone, and human chorionic gonadotropin (hCG).
Which finding in the urine analysis of a pregnant woman is considered a variation of normal? a. Proteinuria b. Glycosuria c. Bacteria in the urine d. Ketones in the urine
b. Glycosuria Small amounts of glucose may indicate "physiologic spilling."
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? A) "You should go ahead and push to assist the delivery." B) "You should try to pant as the delivery proceeds." C) "You should try to perform slow-paced breathing." D) "You should take a deep, cleansing breath and breathe naturally."
B) "You should try to pant as the delivery proceeds." Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head.
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? A) Decreased vaginal discharge B) A surge of energy C) Urinary retention D) Weight gain of 0.5 to 1.5 kg
B) A surge of energy Prior to the onset of labor, the pregnant client experiences a surge of energy.
A pregnant woman's mother is worried that her daughter is not "big enough" at 20 weeks. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman's umbilicus. What should the nurse report to the woman and her mother? a. "The body of the uterus is at the belly button level, just where it should be at this time." b. "You're right. We'll inform the practitioner immediately." c. "When you come for next month's appointment, we'll check you again to make sure that the baby is growing." d. "Lightening has occurred, so the fundal height is lower than expected."
a. "The body of the uterus is at the belly button level, just where it should be at this time." At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks of gestation is located at the level of the umbilicus.
Nurses Notes Client reports a recent episode of painful sores on the perineum, and muscle aches and chills for about 2 weeks. Client currently denies pain but reports sitting is uncomfortable at times. Client denies dysuria and reports mild vaginal itching. Physical Examination: Perineal check reveals small pinpoint open vesicles and pustules on the labia majora with clear drainage noted. Thick, mucopurulent vaginal discharge noted on the client's perineal pad. Vital Signs Temperature 38.2° C (100.9° F) Heart rate 88/min Respiratory rate 20/min Blood pressure 122/58 mm Hg The nurse should anticipate a provider prescription for ____ as evidenced by the client's ________
Acyclovir is correct. Acyclovir is an antiviral medication used to treat certain viral infections, such as genital herpes. The client is exhibiting manifestations of genital herpes, which include open vesicles and pustules on the labia majora, labia minora, and perineum, draining pus with an erythematous base, not feeling well, and thick mucus vaginal discharge. The nurse should anticipate a provider prescription for acyclovir to help decrease the manifestations associated with genital herpes. Perineal lesions is correct. The client is exhibiting manifestations of genital herpes, which include open vesicles and pustules on the labia majora, labia minora, and perineum. The nurse should anticipate a provider prescription for acyclovir as evidenced by the client's perineal lesions.
A nurse is providing teaching to a client who is planning on becoming pregnant about the changes she should expect. Identify the sequence of maternal changes. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Quickening Lightening Goodell's Sign Amenorrhea
Amenorrhea, a presumptive sign of pregnancy, is one of the first physiological indications of pregnancy that occurs by 4 weeks of gestation. Goodell's sign, a probable sign of pregnancy, is the next of physiological indications to occur. Goodell's sign is the softening of the cervix that typically occurs at 5 to 6 weeks of gestation. Quickening, the mother's perception of the first fetal movement, is a presumptive sign of pregnancy that typically occurs between 16 and 20 weeks of gestation. Lightening is the last of these physiological signs of pregnancy to occur. As the fetus descends into the pelvic cavity the fundal height decreases, which typically occurs between 38 and 40 weeks of gestation.
A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? A) "Refrain from exercises that include stretching." B) "Moderate exercise improves circulation." C) "It is recommended to increase your weight-bearing exercises." D) "It is recommended to rest for 30 minutes before each new exercise."
B) "Moderate exercise improves circulation." Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone.
A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? A) "It would be best if you gained about 11 to 20 pounds." B) "The recommendation for you is about 15 to 25 pounds." C) "A gain of about 25 to 35 pounds is recommended for you." D) "A gain of about 1 pound per week is the best pattern for you."
B) "The recommendation for you is about 15 to 25 pounds."' Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb). The pattern of weight gain is also important, with minimal gain in the first trimester.
A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? A) A client who has mitral valve prolapse B) A client who has been exposed to AIDS C) All of the clients D) A client who has a history of preterm labor
C) All of the clients MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.
A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? A) "I will reduce my stress level." B) "I will tell my doctor before using home remedies for nausea." C) "I will monitor my weight gain during the remaining months." D) "I will use only nonprescription medications while pregnant."
D) "I will use only nonprescription medications while pregnant." Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy.
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A) "It's a minor inconvenience, which you should ignore." B) "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." C) "There is no way to predict how long it will last in each individual client." D) "It occurs during the first trimester and near the end of the pregnancy."
D) "It occurs during the first trimester and near the end of the pregnancy." Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.
A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus? A) Calcium B) Iron C) Vitamin C D) Folic acid
D) Folic acid Adequate amounts of folic acid before conception and during the first trimester of pregnancy are necessary for fetal neural tube development. This vitamin helps prevent spina bifida and other neurological disorders.
A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make? A) Retained bile in the liver results in delayed digestion. B) Increased estrogen production causes increased secretion of hydrochloric acid. C) Pressure from the growing uterus displaces the stomach. D) Increased progesterone production causes decreased motility of smooth muscle.
D) Increased progesterone production causes decreased motility of smooth muscle. Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn.
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A) Left lower B) Right lower C) Left upper D) Right upper
D) Right upper Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A) The client is not experiencing a rubella infection at this time. B) The client is immune to the rubella virus. C) The client requires a rubella vaccination at this time. D) The client requires a rubella immunization following delivery.
D) The client requires a rubella immunization following delivery. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? A) The fetal head is in the left occiput posterior position. B) The largest fetal diameter has passed through the pelvic outlet. C) The posterior fontanel is palpable. D) The lowermost portion of the fetus is at the level of the ischial spines.
D) The lowermost portion of the fetus is at the level of the ischial spines. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? A) Cephalic B) Transverse C)Posterior D)Frank breech
D)Frank breech With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.
A pregnant woman has come to the emergency department with complaints of nasal congestion and epistaxis. What is the correct interpretation of these symptoms by the practitioner? a. These conditions are abnormal. Refer the patient to an ear, nose, and throat specialist. b. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.
d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds. As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy
While you are assessing the vital signs of a pregnant woman in her third trimester, the patient complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? a. Have the patient stand up and retake her blood pressure. b. Have the patient sit down and hold her arm in a dependent position. c. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms. d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes
d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension.
