Maternity & Child Exam 8
A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement if made by the client indicates a need for further education? A "I need to be aware of any infections and report signs of infection immediately to my health care provider." B "I need to stay on the diabetic diet." C "I will perform glucose monitoring at home." D "I need to avoid exercise because of the negative effects of insulin production."
"I need to avoid exercise because of the negative effects of insulin production." Rationale: Exercise is safe for the client with gestational diabetes and is helpful in lowering the blood glucose level.
A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2013. Using Naegele's rule, the nurse determines the estimated date of confinement as: A June 12, 2014 B July 12, 2014 C July 26, 2013 D June 26, 2014
June 26, 2014 Rationale: Accurate use of Naegele's rule requires that the woman have a regular 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period, subtract three months, and then add one year to that date.
At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions. The nurse instructs the client to: A Take 10 grains of aspirin for the discomfort Walk around until they subside C Time contraction for 30 minutes Lie down until they stop
Walk around until they subside Rationale: Ambulation relieves Braxton Hicks
A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sign. The nurse determines this sign indicates: A The presence of fetal movement B A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus. C A softening of the cervix D The presence of hCG in the urine
A softening of the cervix Rationale: In the early weeks of pregnancy the cervix becomes softer as a result of increased vascularity and hyperplasia, which causes the Goodell's sign.
The nurse is aware than an adaptation of pregnancy is an increased blood supply to the pelvic region that results in a purplish discoloration of the vaginal mucosa, which is known as: A Goodell's sign B Ladin's sign C Hegar's sign D Chadwick's sign
Chadwick's sign Rationale: A purplish color results from the increased vascularity and blood vessel engorgement of the vagina.
A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A Administer oxygen by face mask B Administer magnesium sulfate intravenously C Assess the blood pressure and fetal heart rate D Clean and maintain an open airway
Clean and maintain an open airway The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.
A pregnant client calls the clinic and tells a nurse that she is experiencing leg cramps and is awakened by the cramps at night. To provide relief from the leg cramps, the nurse tells the client to: A Dorsiflex the foot while extending the knee when the cramps occur B Plantar flex the foot while flexing the knee when the cramps occur C Dorsiflex the foot while flexing the knee when the cramps occur D Plantar flex the foot while extending the knee when the cramps occur
Dorsiflex the foot while extending the knee when the cramps occur Rationale: Legs cramps occur when the pregnant woman stretches the leg and plantar flexes the foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping.
A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is: A G5 T2 P2 A1 L4 B G4 T3 P2 A1 L4 C G4 T3 P1 A1 L4 D G5 T2 P1 A1 L4
G5 T2 P1 A1 L4 Rationale: 5 pregnancies; 2 term births; twins count as 1; one abortion; 4 living children.
A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A Respiratory rate of 10 BPM B Deep tendon reflexes of 2+ C Urinary output of 20 ml since the previous assessment D Fetal heart rate of 120 BPM
Respiratory rate of 10 BPM Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus.
A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A The blood pressure decreases B Ankle clonus in noted C Scotomas are present D Seizures do not occur
Seizures do not occur Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Ankle clonus indicated hyperreflexia and may precede the onset of eclampsia. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure.
A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of: A Two umbilical arteries and one umbilical vein B Two umbilical veins and one umbilical artery C Veins carrying deoxygenated blood to the fetus D Arteries carrying oxygenated blood to the fetus
Two umbilical arteries and one umbilical vein Rationale: Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus.
A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant client to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term? A "It is the thinning of the lower uterine segment." B "It is the fetal movement that is felt by the mother." C "It is the irregular, painless contractions that occur throughout pregnancy." D "It is the soft blowing sound that can be heard when the uterus is auscultated."
"It is the fetal movement that is felt by the mother." Rationale: Quickening is fetal movement and may occur as early as the 16th and 18th week of gestation, and the mother first notices subtle fetal movements that gradually increase in intensity. Braxton Hicks contractions are irregular, painless contractions that may occur throughout the pregnancy. A thinning of the lower uterine segment occurs about the 6th week of pregnancy and is called Hegar's sign.
In the 12th week of gestation, a client completely expels the products of conception. Because the client is Rh negative, the nurse must: A Administer RhoGAM within 72 hours B Not give RhoGAM, since it is not used with the birth of a stillborn C Make certain she receives RhoGAM on her first clinic visit D Make certain the client does not receive RhoGAM, since the gestation only lasted 12 weeks.
Administer RhoGAM within 72 hours Rationale: RhoGAM is given within 72 hours postpartum if the client has not been sensitized already.
The nurse recognizes that an expected change in the hematologic system that occurs during the 2nd trimester of pregnancy is: A A decrease in sedimentation rate B In increase in hematocrit C An increase in blood volume D A decrease in WBC's
An increase in blood volume Rationale: The blood volume increases by approximately 40-50% during pregnancy. The peak blood volume occurs between 30 and 34 weeks of gestation. The hematocrit decreases as a result of the increased blood volume.
A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: A Enlargement of the breasts B Complaints of feeling hot when the room is cool C Any bleeding, such as in the gums, petechiae, and purpura. D Periods of fetal movement followed by quiet periods
Any bleeding, such as in the gums, petechiae, and purpura Severe Preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.
The nurse teaches a pregnant woman to avoid lying on her back. The nurse has based this statement on the knowledge that the supine position can: A Unduly prolong labor B Interfere with free movement of the coccyx C Lead to transient episodes of hypotension D Cause decreased placental perfusion
Cause decreased placental perfusion Rationale: This is because impedance of venous return by the gravid uterus, which causes hypotension and decreased systemic perfusion.
A nurse is performing an assessment of a primipara who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing? A Braxton hicks contractions B Fetal heart rate of 180 BPM C Consistent increase in fundal height D Quickening
Fetal heart rate of 180 BPM The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160-170 BPM in the first trimester and slows with fetal growth, near and at term, the fetal heart rate ranges from 120-160 BPM. The other options are expected
The chief function of progesterone is the: A Stimulation of the follicles for ovulation to occur B Preparation of the uterus to receive a fertilized egg C Development of the female reproductive system D Establishment of secondary male sex characteristics
Preparation of the uterus to receive a fertilized egg Rationale: Progesterone stimulates differentiation of the endometrium into a secretory type of tissue
A 26-year old multigravida is 14 weeks' pregnant and is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does the alpha-fetoprotein test indicate?" The nurse bases a response on the knowledge that this test can detect: A Cardiac defects B Neural tube defects C Urinary tract defects D Kidney defects
Neural tube defects Rationale: The alpha-fetoprotein test detects neural tube defects and Down syndrome.
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A Proteinuria of +3 B Respirations of 10 per minute C Presence of deep tendon reflexes D Serum magnesium level of 6 mEq/L
Respirations of 10 per minute Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden drop in the fetal heart rate and maternal heart rate and blood pressure. Therapeutic levels of magnesium are 4-7 mEq/L. Proteinuria of +3 would be noted in a client with preeclampsia.
An expected cardiopulmonary adaptation experienced by most pregnant women is: A Dyspnea at rest B Shortness of breath on exertion C Progression of dependent edema D Tachycardia
Shortness of breath on exertion Rationale: This is an expected cardiopulmonary adaptation during pregnancy; it is caused by an increased ventricular rate and elevated diaphragm.
Which of the following terms applies to the tiny, blanched, slightly raised end arterioles found on the face, neck, arms, and chest during pregnancy? A Linea nigra B Epulis C Striae gravidarum D Telangiectasias
Telangiectasias The dilated arterioles that occur during pregnancy are due to the elevated level of circulating estrogen. The linea nigra is a pigmented line extending from the symphysis pubis to the top of the fundus during pregnancy.
A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? A Dependent edema has resolved B The client complains of a headache and blurred vision C Urinary output has increased D Blood pressure reading is at the prenatal baseline
The client complains of a headache and blurred vision If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening Preeclampsia.
A pregnant woman at 32 weeks' gestation complains of feeling dizzy and lightheaded while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to: A Turn the woman on her side. B Have the woman breathe into a paper bag C Raise the woman's legs D Assess the woman's blood pressure and pulse
Turn the woman on her side. Rationale: During a fundal height measurement the woman is placed in a supine position. This woman is experiencing supine hypotension as a result of uterine compression of the vena cava and abdominal aorta. Turning her on her side will remove the compression and restore cardiac output and blood pressure. Then vital signs can be assessed. Raising her legs will not solve the problem since pressure will still remain on the major abdominal blood vessels, thereby continuing to impede cardiac output. Breathing into a paper bag is the solution for dizziness related to respiratory alkalosis associated with hyperventilation.
A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. A Fetal heart rate detected by nonelectric device B Uterine enlargement C Braxton Hicks contractions D Ballottement E Chadwick's sign F Outline of the fetus via radiography or ultrasound
Uterine enlargement Braxton Hicks contractions Ballottement Chadwick's sign Rationale: The probable signs of pregnancy include: Uterine Enlargement Hegar's sign or softening and thinning of the uterine segment that occurs at week 6. Goodell's sign or softening of the cervix that occurs at the beginning of the 2nd month Chadwick's sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. Ballottement or rebounding of the fetus against the examiner's fingers of palpation Braxton-Hicks contractions Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG Active fetal movement palpable by the examiners Outline of the fetus via radiography or ultrasound
A prenatal nurse is providing instructions to a group of pregnant client regarding measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further instructions? A "I need to cook meat thoroughly." B "I need to avoid touching mucous membranes of the mouth or eyes while handling raw meat." C "I need to drink unpasteurized milk only." D "I need to avoid contact with materials that are possibly contaminated with cat feces."
"I need to drink unpasteurized milk only." Rationale: All pregnant women should be advised to do the following to prevent the development of toxoplasmosis. Women should be instructed to cook meats thoroughly, avoid touching mucous membranes and eyes while handling raw meat; thoroughly wash all kitchen surfaces that come into contact with uncooked meat, wash the hands thoroughly after handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption, and avoid contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sandboxes, and garden soil.
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further education? A "I will maintain strict bedrest throughout the remainder of pregnancy." B "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding." C "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." D "I will watch for the evidence of the passage of tissue."
"I will maintain strict bedrest throughout the remainder of pregnancy." Rationale: Strict bed rest throughout the remainder of pregnancy is not required. The woman is advised to curtail sexual activities until the bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the physician. The woman is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The woman also should watch for the evidence of the passage of tissue.
Which of the following symptoms occurs with a hydatidiform mole? A Heavy, bright red bleeding every 21 days B "Snowstorm" pattern on ultrasound with no fetus or gestational sac C Fetal cardiac motion after 6 weeks gestation D Benign tumors found in the smooth muscle of the uterus
"Snowstorm" pattern on ultrasound with no fetus or gestational sac Rationale: The chorionic villi of a molar pregnancy resemble a snowstorm pattern on ultrasound. Bleeding with a hydatidiform mole is often dark brown and may occur erratically for weeks or months.
A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? A Facial edema B Increased respirations C Negative urinary protein D Elevated blood pressure
Elevated blood pressure The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia
When involved in prenatal teaching, the nurse should advise the clients that an increase in vaginal secretions during pregnancy is called leukorrhea and is caused by increased: A Functioning of the Bartholin glands B Production of estrogen C Supply of sodium chloride to the cells of the vagina D Metabolic rates
Production of estrogen Rationale: The increase of estrogen during pregnancy causes hyperplasia of the vaginal mucosa, which leads to increased production of mucus by the endocervical glands. The mucus contains exfoliated epithelial cells.
