Maternity- Obstetrical Assessment

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? 1. it is the fetal movement that is felt by the mother 2. it is the compressibility of the lower uterine segmant 3. it is the irregular, painless contractions that occur throughout pregnancy 4. it is the soft blowing sound that can be heard when the uterus is auscultated

1 Rationale: quickening is fetal movement that appears usually at 16 to 20 weeks, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. a compressibility of the lower uterine segment occurs at about 6 weeks gestation and is called Hegars sign. braxton hicks contactions are irregular, painless contractions that may occur throughout pregnancy. a soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus, this is known as uterine souffle. this sound is the result of blood circulation to the placenta, and it corresponds with the maternal pulse

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy that the nurse should note? SATA 1. ballottement 2. chadwicks sign 3. uterine enlargement 4. braxton hicks contractions 5. outline of fetus via radiography or ultrasound 6. fetal heart rate detected by a nonelectronic device

1, 2, 3, 4 Rationale: the probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodells sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy), chadwicks sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiners fingers on palpation), braxton hicks contractions, and a positive pregnancy test that measure for human chorionic gonadotropin. positive signs of pregnancy include a FHR that is detected by an electronic device at 10 to 12 weeks and by a fetoscope at 20 weeks.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the HCP has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which? 1. a softening of the cervix 2. the presence of fetal movement 3. the presence of human chorionic gonadotropin 4. a soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

1 Rationale: during the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. cervical softening is noted by the examiner during a pelvic examination. goodell's sign does not indicate the presence of fetal movement. human chorionic gonadotropin is noted in maternal urine with a positive urine pregnancy test. a soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus, it is the result of blood circulating through the placenta

The nurse is collecting data from a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and should expect which finding? 1. 22cm 2. 28cm 3. 36cm 4. 40cm

2 Rationale: during the second and third trimesters (18-30 weeks), the fundal height in centimeters approximately equals the fetuses's age in weeks plus or minuts 2cm. at 14 to 16 weeks gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. at 20 to 22 weeks, the fundus is at the umbilicus, and at term, the fundus is at the xiphoid process

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3 year old child who was born at 39 weeks gestation. The nurse should document which gravida and para status on this client? 1. gravida I, para I 2. gravida II, para I 3, gravida II, para II 4. gravida III, para II

2 Rationale: gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. parity is a term that means the number of births after 20 weeks gestation; it does not reflect the number of fetuses or infants.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nagele's rule, the nurse determines the estimated date of birth is which? 1. july 12, 2017 2. july 27, 2017 3. august 12, 2017 4. august 27, 2017

2 Rationale: the accurate use of Nagele's rule requires that the woman have a regular 28 day menstrual cycle. subtract 3 months from the first day of her last period, add 7 days, and then adjust the year as appropriate. in this case, the first day of the LMP was October 20, 2017. When you subtract 3 months, you get July 20, 2017. if you add 7 days, you get July 27, 2016. add 1 year to this, and you get the estimated date of birthL July 27, 2017

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton hicks contactions. Based on this finding, which nursing action is appropriate? 1. contact the HCP 2. instruct the client to maintain bed rest for the remainder of pregnancy 3. tell the client that these are common and they may occur throughout the pregnancy 4. call the maternity unit and inform them that the client will be admitted in a prelabor condition

3 Rationale: braxton hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. because braxton hicks contractions may occur and are normal in some pregnant women during pregnacy, options 1,2, and 4 are unnecessary

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 weeks gestation 2. 8 and 10 weeks gestation 3. 10 and 12 weeks gestation 4. 16 and 20 weeks gestation

4 Rationale: quickening is fetal movement that usually first occurs between 16 and 20 weeks gestation. the expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity.

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing? 1. quickening 2. braxton hicks contractions 3. consistent increase in fundal height 4. fetal heart rate of 180 beats per minute

4 Rationale: the fetal heart rate depends on the gestational age. is is 160 to 170 bpm during the first trimester, and it slows with fetal growth to approx 120-160 bpm.

The nurse is collecting date form a client who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document the GTPAL for this client as which? 1. G=3, T=2, P=0, A=0, L=1 2. G=2, T=1, P=0, A=0, L=1 3. G=1, T=1, P=1, A=0, L=1 4. G=2, T=o, P=0, A=0, L=1

2 Rationale: pregnancy outcomes can be described with the GTPAl acronym: G=gravidity (number of pregnancies); T=term births (number born after 37 weeks); P=preterm births (number born before 37 weeks); A=abortions/miscarriages (number of abortions/miscarriages); L=live births (number of live births or living children). therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. because the child was delivered at 38 weeks, the number of preterms is 0, and the number is term births is 1. the number of abortions is 0, and the number is live births is 1