NCLEX: Maternity - Antepartum

3844: A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement would the nurse provide to the client?

"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

3845: A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client?

"Better blood glucose control means fewer effects: let's review your plan of care."

2461: The nursing instructor asks the nursing student to identify the reason that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which response indicates that the student understands the rationale of this physiological response?

"Blood volume and cardiac output increase resulting in a faster pulse."

3839: The nurse is caring for a pregnant client who was diagnosed w acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breastfeed the infant after delivery. Which response by the nurse is appropriate?

"Breastfeeding is contraindicated."

1792: A pregnant client is positive for the human immunodeficiency virus (HIV). The nurse educates the client and determines that there is a need for further teaching if the client makes which statement?

"Breastfeeding my newborn will be the best option for my baby."

2149: A young pregnant woman w diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, which is the best response by the nurse?

"Can you tell me more about what you are eating?"

3468: The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking, and the client tells the nurse that she has been taking the herb chamomile. Which statement made by the client demonstrates correct information about this herbal intervention?

"Chamomile should not be used while I am pregnant and because I have asthma."

2531: When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?

"Do you have any cats as house pets, and if so, do you ever come in contact w their soiled kitty litter?"

0205: A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?

"Do you plan to have any other children?"

2280: A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids?

"Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."

2282: During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily w brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement?

"I am eating fresh fruits and vegetables for snacks and for dessert each day."

1790: A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?

"I am so glad that I can breastfeed my baby after she has been vaccinated."

1793: The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation?

"I don't like my face anymore. I always look like I have been crying."

2287: The nurse employed in a PHCP's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral?

"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

2544: The nurse collects data from a pregnant client diagnosed w iron deficiency anemia during her third trimester for additional risk factors associated w the anemia. Which statement made by the client would the nurse question to receive more information?

"I have had mild vaginal spotting twice since my last prenatal visit."

2364: The nurse reinforces instruction to a client w mild preeclampsia on home care. Which comment by the client indicates that teaching is effective?

"I need to check my urine w a dipstick every day for protein and call my health care provider if it is 2+ or more."

2975: The nurse is prenatal clinic is taking a nutritional history from a pregnant adolescent . Which statement by the client would alert the nurse to potential concern regarding adequate nutritional intake during the pregnancy?

"I need to gain only 10 pounds so that my baby will be small like I am."

0224: During a prenatal visit, the nurse is explaining dietary management to a client w diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

2105: A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client indicates that she understands her needs?

"I should avoid stressful situations."

2351: A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?

"I should choose underwear w a cotton panel liner."

1551: The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."

2428: The nurse is caring for a client diagnosed w preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia?

"I should expect that my urine output will decrease."

2984: A maternity nurse is caring for a client who is admitted to the hospital w a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes?

"I shouldn't have eaten so many sweets before I became pregnant."

0217: The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about the Rh sensitization when the client makes which statement?

"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

2298: A perinatal client w a history of heart disease has been instructed on care at home. Which statement made by the client indicates the need for further teaching?

"It is best to rest on my right side."

0215: The nurse instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

2184: A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born w an infection. Which response would the nurse make to help reduce the maternal fears that the newborn will be born w an infection?

"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."

3298: The nurse is assisting in conducting a prenatal session w a group of expectant parents. Which comment related to female hormones made by a parent indicates the need for further teaching?

"Prolactin is the hormone responsible for the initiation of labor."

3120: The nurse is conducting a prenatal session w a group of expectant parents. The nurse recognizes that teaching regarding hormones has been successful if a parent makes which statement?

"Prolactin is the hormone responsible for the secretion of milk."

2429: A client at 32 weeks of gestation w a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic?

"Tell me about your concerns."

2974: A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?

"Tell me what concerns you have."

1731: A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy? Which response is appropriate for the nurse to make?

"The breast changes are a result of the secretion of estrogen and progesterone."

1531: The nurse is reading the PHCP documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included w this pelvic shape? Select all that apply.

- heart shaped - convergent sidewalls - narrow interspinous diameter

2545: A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response best supports the client?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

0223: The nurse has a teaching session w a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning?

"The iron is needed for the red blood cells."

0219: A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."

1721: Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

1706: A woman at 20 weeks of gestation calls the PCHP's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"This is an emergency; you should come to the clinic within the hour."

2533: The nurse shares w a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?

"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

2279: A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has places a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?

"You feel you are having difficulty fulfilling your role as a wife."

1726: A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child w rubella. Which response by the nurse is appropriate?

"You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."

3140: A client w type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a PHCP's visit. The client asks the nurse whether a change in the medications to treat the diabetes will occur at this time. Which statement is true?

"Your normal insulin dosage will have to be decreased."

1107: The nurse-midwife is conducting a session on the process of conception w a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.

- "Fertilization occurs in the outer third of the fallopian tube." - "Only 1 sperm will penetrate the ovum to produce fertilization." - "Implantation occurs in the anterior or posterior fundal region of the uterus." - "The ovary produces hormones to maintain the pregnancy before placental development."

1108: The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the nurse about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone? Select all that apply.

- "It maintains the uterine lining for implantation." - "It relaxes all smooth muscle, including the uterus."

1515: A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statements by the student indicate an understanding of this hormone? Select all that apply.

- "It may play a role in the neural development of the fetus." - "It increases during pregnancy to stimulate basal metabolic rate."

3834: The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses would the nurse make to the client? Select all that apply.

- "It stimulates the breasts to prepare for lactation." - "It stimulates uterine development to provide an environment for the fetus."

2447: The nurse working in a prenatal clinic receives a telephone call from a client at 22 weeks of gestation. The client reports some vaginal discharge and has started to experience menstrual-like cramps and diarrhea. Which responses by the nurse indicate an understanding of the implications of the client's s/s? Select all that apply.

- "Lie on your left side for an hour and try to drink some fluids." - "It is important that you urinate frequently to keep your bladder empty." - "Palpate for contractions and call back if there are more than four contractions in the next hour." - "Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"

2286: A client who is in the second trimester of pregnancy develops melasma during pregnancy. Which statements made by the client indicate an understanding of this condition? Select all that apply.

- "Melasma may reoccur in a subsequent pregnancy." - "These brown, splotchy patches will most likely disappear after I deliver my baby." - "The dark patches that are on my nose, cheeks, and forehead will most likely darken until the baby is delivered."

1786: A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply.

- "Surfactant, which is needed for lung expansion, is present beginning at 28 weeks." - "W decreased surfactant, more pressure must be generated to produce inspiration." - "Surfactant lowers surface tension, reducing the pressure required to keep the alveoli expanded."

1538: A pregnant woman visiting a health care clinic for the first prenatal visit hears the PHCP discuss the preembryonic period of development w the nurse. The woman asks the nurse what this means. What information would the nurse share related to this stage of development? Select all that apply.

- "The preembryonic period is the first 2 weeks of fetal development following conception." - "The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers."

1730: Which statements made by a nurse student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.

- "hCG is the hormone responsible for a positive pregnancy test." - "hCG may be present as early as 8 to 10 days following conception." - hCG is produced by the trophoblastic cells that surround the developing embryo." - hCG preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

3835: The nurse is reviewing the record of a pregnant client and notes that the PHCP has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply.

- Chadwick's signs is a probable sign of pregnancy. - Chadwick's sign may be present as early as 6 weeks' gestation. - Chadwick's sign is a bluish discoloration of the vagina and cervix.

3289: The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. Which assessment findings are most likely present at this time? Select all that apply.

- Fetal heart tones can be heard by Doppler. - Braxton Hicks contractions may be felt by the mother. - The fundus is located midway between the symphysis pubis and the umbilicus.

3114: A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. The student displays correct understanding if the student lists which signs? Select all that apply.

- Hegar's - Chadwick's - McDonald's

3258: The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply.

- Hegar's sign - Goodell's sign - McDonald's sign

3267: The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to the group?

- The number of RBC will be increased during pregnancy. - At term, the heart rate has increased by 15 to 20 beats per minute. - In a supine position, some degree of compression of the vena cava will occur.

4440: A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice would the nurse provide to this client about ways to assist with this problem? Select all that apply.

- avoid greasy foods - eat 5 to 6 small meals each day - do not drink fluids w meals

0214: The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse would note? Select all that apply.

- ballottement - Chadwick's sign - uterine enlargement - Braxton Hicks contractions

1535: A woman diagnosed previously w gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing s/s that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply.

- blood pressure (BP) 165/120 mmHg - complaints of headache for the last 12 hours

4439: A 26-year-old woman comes to the clinic and asks for a pregnancy test because she thinks she might be pregnant. The nurse assesses for which presumptive signs of pregnancy? Select all that apply.

- breast tenderness - early morning nausea - non menstruation for the last 8 weeks

3497: A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply.

- bypassing the fetal lungs to circulate oxygen rich blood - using the fetus's beating heart to pump blood in the circulatory system - carrying more oxygen on fetal hemoglobin than maternal hemoglobin - making the fetal cardiac output higher per unit of body weight that the maternal cardiac output

4518: The nurse is explaining physiological changes of pregnancy that are related to melanocyte-stimulating hormone (melanotropin). Which pregnancy changes are related to the effects of this hormone? Select all that apply

- chloasma - linea nigra - darkening of areola

3118: A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.

- clear fluid - white flecks in the amniotic fluid - presence of glucose and protein in the amniotic fluid

4443: The nurse is preparing a woman w gestational hypertension for discharge and shares w the client directions to follow which instructions? Select all that apply.

- curtail exercise - measure your blood pressure daily - rest frequently by lying on your side - call the PHCP if you develop dizziness

1785: The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.

- earliest taste buds present - kidneys able to secrete urine - sex can be determined as internal and external organs are sex specific

4519: A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help w morning sickness. Which would the nurse include in the instructions? Select all that apply

- eat a low-fat diet - stop or decrease smoking - eat smaller, more frequent meals - consume adequate fluid between meals

3847: A nurse is monitoring a pregnant client for the warning s/s of gestational hypertension. Which are s/s of this complication of pregnancy? Select all that apply.

- edema - proteinuria - thrombocytopenia

3276: The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the PHCP. Which warning signs would the nurse place on the list? Select all that apply.

- facial edema - rapid weight gain - visual disturbances - generalized edema

3489: A client presents at her PHCP's office 10 weeks pregnant w her first pregnancy. Which are presumptive signs of pregnancy that the client might be expected to have? Select all that apply.

- fatigue - breast changes - nausea and vomiting

1544: The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.

- female organ of coitus - discharge of menstrual flow - allows for fetal passage during the process of birth

3262: The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.

- fetal heart tones - fetal movements felt by examiner

2562: The nurse is collecting data on a client who is pregnant w twins. Which signs would alert the nurse to potential problems specifically related to the twin pregnancy? Select all that apply.

- hypertension - six or more uterine contractions per hour

3121: The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.

- increases blood flow to the uterine vessels - stimulates development of the breast ducts - causes vascular changes in the mucous membranes of the nose and mouth

1542: The nurse is collecting data from a pregnant client w a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.

- legs - vulva

3141: The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply.

- liver - beans

3122: The nurse is reading the PHCP's documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. Which descriptions apply to an android pelvis? Select all that apply.

- narrow wedge shape - unfavorable for a vaginal birth

2901: The nurse is collecting data on a client w severe preeclampsia. Which s/s are noted in severe preeclampsia? Select all that apply.

- oliguria - proteinuria 3+ - blood pressure 168/116 mmHg

0840: A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

- oranges - broccoli - grapefruit

3102: The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.

- peanut butter - whole grain bread - omelet w cheese

2291: The nurse is collecting data from a client who is pregnant w twins. The nurse understands that which complications are more likely to occur w a twin pregnancy? Select all that apply.

- preterm labor - maternal anemia

0230: The nurse is monitoring a pregnant client w gestational hypertension (GH) who is at risk for preeclampsia. The nurse would check the client for which signs of preeclampsia? Select all that apply.

- proteinuria - hypertension

3101: The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.

- pulse - blood volume - cardiac output - RBC mass

2539: During an initial prenatal visit, the nurse notes that the PHCP documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply.

- reports of fatigue - pink mucous membranes

0277: A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply.

- respirations of 10 breaths/minute - urine output of 20 mL in an hour

3496: A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones would the nurse identify as resent at this time? Select all that apply.

- sex recognizable - blood forming in marrow - kidneys able to secrete urine

1548: The nurse is reading the PHCP documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.

- shallow depth - wide suprapubic arch - compatible w vaginal delivery - flattened anteroposteriorly and wide transversely

1709: The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

- small parts are located on the left side of the uterus - small parts are located on the right side of the uterus - a soft, irregular non-ballottable shape is located just above the symphysis pubis

3278: A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions would the nurse place on the list? Select all that apply.

- to note the color of blood on each perineal pad - to watch for the evidence of the passage of tissue - to note the quantity of blood on each perineal pad - to count the number of perineal pads used on a daily basis

4438: The nurse is discussing prenatal testing w a woman who is approximately 6 weeks pregnant. The nurse shares which tests re expected to be conducted during the first trimester? Select all that apply.

- urinalysis - rubella titer - complete blood count

4444: The nurse is working w a woman who has just been diagnosed w gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.

- urinary tract infections - increased chance of cesarean birth - delayed lung maturation in the neonate

0276: The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings would cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply.

- uterine hyperstimulation - late decelerations of the fetal heart rate

2986: The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated w this diagnosis? Select all that apply.

- vaginal bleeding - excessive vomiting - no fetal heart activity - larger than normal uterine size - elevated levels of human chorionic gonadotropin (hCG)

3119: The PHCP is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.

- vaginal secretions increase - bluish discoloration of the vagina - higher levels of glycogen in vaginal secretions

0198: The nurse working in a prenatal clinic reviews a client's chart and notes that the PHCP documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.

-round shape -diagonal conjugate measures 12.5 cm to 13 cm -blunt, somewhat widely separate ischial spines

1796: The nurse is collecting data from a client w placenta previa during an office visit. The nurse would check which item as first priority?

signs of fetal distress

1545: A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?

12 to 16 weeks

0202: During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?

150 beats per minute

0207: 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?

16 and 20 weeks' gestation

1060: A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

18

3836: The nurse is reviewing the health care record for a pregnant client at 24 weeks' gestation. The nurse would anticipate that the fundus would be located at which level?

22 cm to 26 cm

0212: The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and would expect which finding?

26 cm

0209: The nurse is collecting data from a client who is pregnant w triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse would document which gravida and para status on this client?

Gravida II, para I

1110: The nurse is providing instructions to a pregnant client w genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

3257: The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the PHCP?

fundal height, 38 cm

3840: 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 should be noted at which time interval?

Between 10 to 20 weeks' gestation

3112: The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen?

Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

2538: A woman is 24 weeks pregnant. She had a previous stillborn neonate at 38 weeks' gestation and a pregnancy that ended at 34 weeks with the birth of a stillborn girl. She states she has a 4-year-old son and an 8-year-old daughter who live w her at home and were both born at 38 weeks. What is her gravidity and parity, using the five-digit system (GTPAL)?

G (5) T (3) P (1) A (0) L (2)

0208: The nurse is collecting data from a client who is pregnant w 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 would document which as the GTPAL for this client?

G = 2 T = 1 P = 0 A = 0 L = 1

3838: A pregnant client is seen in the heath care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action would the nurse take?

Instruct the client that these are common and my occur throughout the pregnancy.

0203: The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

2903: A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nagele's rule, which is the estimated date of delivery (EDD)?

January 12

0206: 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 (LMP) was October 20, 2022. Using Nagele's rule, the nurse determines the estimated date of birth is which date?

July 27, 2023

2537: The nurse encourages the childbearing woman diagnosed w human immunodeficiency virus (HIV) to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?

Minimize the potential for developing infections.

2446: The nurse is working w a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as an effective teaching method?

Palpate for uterine contractions at the same time as the client.

2438: The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie don on the examining table. Her skin is pale and is both cool and moist to the touch. Which action would the nurse perform first?

Place a wedge pillow under the client's right side (symptoms suggest supine hypotension caused by compression of the aorta and inferior vena cava by the gravid uterus).

3762: The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which misunderstanding on the part of the client about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother.

2352: During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presences of HIV?

T lymphocyte levels

0216: The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions would the nurse reinforce to the client?

The bladder must be full during the examination.

0213: 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 contractions. Based on this finding, which nursing action is appropriate?

Tell the client that these are common and they may occur throughout the pregnancy.

1111: Which would be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

Tell the dental office staff that she is pregnant.

2361: A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem would initially direct nursing care at this time?

The client is blaming herself.

2356: The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?

The client will be able to identify measures to prevent infection.

1066: The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?

The client will feel some pressure when the vaginal probe is moved.

2353: When caring for the pregnant client w human immunodeficiency virus (HIV), which goal is appropriate?

The client will not develop an opportunistic infection during the remainder of pregnancy.

1862: The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

3275: A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription would the nurse anticipate for the client?

a 3-hour glucose tolerance test

2368: When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors would the nurse consider significant?

a client who is gravida II who has just been diagnosed w dead fetus syndrome; fetal demise occurred 2 months ago

0221: The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult w the dietitian to ensure which dietary measure?

a diet that is high in fluids and fiber to decrease constipation

1115: The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

a history of intravenous (IV) drug use in the past year

2290: A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation would the nurse make of these results?

a negative test

0210: 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 PHCP has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs w pregnancy?

a softening of the cervix

2370: The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?

a urinary tract infection

1062: A pregnant client in the second trimester of pregnancy is admitted to the maternity unit w a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if this condition is present?

abdominal pain

2158: The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation?

acute anxiety and the need for support

3292: A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which would the nurse determine is a harmful measure in preventing constipation?

adding 1 tablespoons of mineral oil to a bowl of cereal daily (mineral oil should not be used as a stool softener because it inhibits the absorption of fat-soluble vitamins in the body)

3117: A hepatitis B screen is performed on a pregnant client , and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?

administration of immune globulin and vaccine in the infant soon after birth

3260: A client in her 24th week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test would the nurse expect the PHCP to prescribe?

amniocentesis for fetal surfactant level

1561: The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

an adolescent w multiple heterosexual contacts

2367: A pregnant client has just been admitted to the hospital w severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment would be part of the plan of care?

any bleeding, such as in the gums, petechiae, and purpura (bleeding is an early sign of disseminated intravascular coagulation (DIC), a complication of preeclampsia, and should be reported)

2535: The nurse instructs a pregnant client diagnosed w human immunodeficiency virus (HIV) to report immediately to the PHCP any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?

assists in identifying infections that may need to be treated

1116: A prenatal client is at risk for toxoplasmosis. Which instruction would the nurse reinforce w the client to prevent exposure to this disease?

avoid exposure to litter boxes used by cats

1559: The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal?

avoid further stress on the maternal immune system

2987: The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?

green, leafy vegetables

2288: A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?

hemoglobin 9.1 g/dL

2363: During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which would the nurse check further?

blood pressure changes and the presence of protein in the urine

0750: The nurse is assisting w caring for a client who has a placenta previa. The nurse understands that a cervical examination would not be performed on the client primarily because it could have which consequence?

cause hemorrhage

2787: Which history places a maternity client at risk for uterine rupture?

cesarean section birth

1065: A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, which would the nurse do first?

check for signs of thrombophlebitis

0218: While assisting w the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason?

compression of the vena cava

0201: A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

connects the umbilical vein to the inferior vena cava

2426: A pregnant client is seen in the health care clinic w reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion?

consume dry crackers before getting out of bed

1558: The nurse is reinforcing instructions to a maternity client on how to keep the fetal activity diary. Which instruction would the nurse provide the client?

contact the PHCP if the baby's movements are fewer than 10 times in 2 hours

0211: A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?

fetal heart rate of 180 beats per minute

1552: The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?

fresh spinach

3002: The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which would the nurse specifically monitor?

deep tendon reflexes (loss of reflexes is often the first sign of developing toxicity)

2283: The nurse is assigned to care for a pregnant client w a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem would receive highest priority?

dehydration

2976: The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?

describing the appropriate amount of weight gain required during the pregnancy

3261: The nurse is collecting data on a pregnant client in her 22nd week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action would the nurse take?

document the assessment

3116: The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2 F. Which nursing action is appropriate?

document the temperature

0227: The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and would tell the client to perform which measure?

dorsiflex the client's foot while extending the knee

2978: The nurse is reinforcing dietary instructions to a pregnant client w a history of lactose intolerance. The nurse would instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?

dried fruits

0228: The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse would instruct the client to take which best measure?

drink decaffeinated coffee and tea

1791: In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

establish a therapeutic relationship between the nurse and the pregnant client.

2297: During an office visit, a prenatal client w mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time?

explain the purpose of the nurse's actions and answer all questions

3389: When planning care for a woman w gestational hypertension (GH), the nurse plans to encourage which maternal behavior?

expression of hope for a positive outcome

2299: A primigravida client comes to the clinic and has been diagnosed w a UTI. She has repeatedly verbalized concern regarding safety of the fetus. Which client problem does the nurse identify as the priority at this time?

fear about the well-being of the fetus

2360: A client who is 6 months pregnant is attending her first prenatal visit. On the first prenatal visit, the nurse notes that the client is gravida 4, para 0, abortion 3. The client is 5'6", weights 130 lbs and is 25 years old. She states "I get really tired after working all day and can't keep up w my housework." Which factor in the above data would lead the nurse to suspect gestational diabetes?

fetal demise

2354: A prenatal client diagnosed w anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem does the data best support?

high risk for infection

2514: The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

history of substance abuse during this pregnancy

2199: The nurse is assisting in developing a teaching plan for a pregnant client diagnosed w diabetes mellitus. Which instruction is the priority for this client?

how to check for signs of hypoglycemia and the required treatment

3833: A client calls the PHCP's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine?

human chorionic gonadotropin (hCG)

1541: The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position would the nurse place to client?

in a sitting position

2296: The nurse is gathering data from a prenatal client w heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?

increase in circulating volume

2185: The nurse is collecting data on a pregnant woman who is diagnosed w human immunodeficiency virus (HIV) during the thirty-second gestational week. The nurse reviews the data and determines that which finding requires further follow-up?

increased SOB and bilateral rales

2467: The nurse is reviewing the laboratory results of a pregnant client and notes that the hemoglobin level is decreased. Physiological dilutional anemia is documented in the client's record by the PHCP. The nurse plans care, knowing that this type of anemia is a result of which situation?

increased blood volume of the mother during pregnancy

2980: A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the result were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?

inevitable (an inevitable abortion is a termination of pregnancy that cannot be prevented. Moderate to severe bleeding w mild abdominal cramping and cervical dilation is present)

2449: During a prenatal visit of a client diagnosed w placenta previa, the PHCP defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk?

initiating severe hemorrhage

1543: A pregnant client is seen in the health care clinic for regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action would be appropriate?

instruct the client that these are common and may occur throughout the pregnancy

1537: The nurse is reinforcing instructions to a pregnant client about what the warning signs in pregnancy that require the need to notify the PHCP. The nurse determines that further teaching is needed if the client states that it is necessary to call the PHCP if which occurs?

irregular, painless contractions

2300: A prenatal client has acquired the STI condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment would the nurse consider to be safe for this client?

laser therapy

1787: The nurse is preparing to monitor a fetal heart rate. The nurse locates a round, ballottable shape just above the symphysis pubis. Fetal small parts are located on the right side of the uterus w a concave shape located on the left side of the uterus. Where would the nurse listen to hear the strongest fetal heart tones?

left lower quadrant

0226: The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse would recommend which measure to help relieve both discomforts?

lie on the floor w the legs elevated onto a couch or padded chair, w the hips and knees at a right angle

3111: A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?

longest period of fetal development

3842: The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action?

massaging the abdomen during contractions using both hands in a circular motion

2803: The nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record supports this risk factor?

maternal hypertension

3034: The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?

maternal hypertension

0784: The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse would expect to document that the fundus of the uterus is located which area?

midway between the symphysis pubis and the umbilicus

2424: The nurse is assigned to care for a client admitted w severe preeclampsia. Which is the priority nursing intervention for this client?

minimizing the client's exposure to external stimuli

2423: The nurse assigned to care for a client w mild preeclampsia would anticipate which specific nursing intervention for this client?

monitoring fetal movement

1112: The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?

nuts and green, leafy vegetables

1104: A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that primary hormone stimulates postpartum contractions?

oxytocin

2292: The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching would the nurse use?

palpate for uterine contractions at the same time as the client

2278: The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which would the nurse include in the instructions?

perform Kegel exercises in 10 repetitions, three times per day

0222: The nurse caring for a client w abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if which is observed?

petechiae, oozing from injection sites, and hematuria

1533: The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure, the nurse would take which action?

place the client in a supine position and place a wedge under the right hip

2153: A pregnant woman who is at 38 weeks' gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, what does the nurse determine the client may be experiencing?

placenta previa

1566: The nurse is assisting w care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?

placing external fetal monitors so that each fetal heart rate is monitored separately

2518: The nurse is caring for a pregnant client w a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?

potential for infection

1539: The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. According to the nurse, what is the purpose of progesterone?

progesterone maintains the uterine lining for implantation

2355: The nurse is planning interventions for counseling a maternity client newly diagnosed w sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action?

provide emotional support

0199: The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?

provides an exchange of nutrients and waste products between the mother and the fetus.

3843: The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?

providing the mother w pamphlets and booklets to read about the pregnancy

2983: The nurse is preparing to collect data on a client w a possible diagnosis of ectopic pregnancy. Which would the nurse check first?

pulse (primary concern when ectopic pregnancy is suspected is the occurrence of bleeding and hypovolemic shock)

1555: The nurse assists a pregnant client w cardiac disease is identifying resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to accomplish which tasks?

reduce excessive maternal stress and fatigue

2530: The nurse is reinforcing the positive effects of breathing and relaxation techniques to a pregnant client w cardiac issues who has an 18-month-old child. Which primary outcome is the purpose for these interventions?

reducing maternal stress and fatigue

2515: A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?

reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures

2534: A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid and rifampin. The nurse plans to implement which intervention?

reviewing daily nutritional intake w the client

2952: The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The PHCP performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?

second

3137: The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during the pregnancy?

she has a history of chronic hypertension

1550: The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse would tell the client that these exercises are for which purpose?

strengthen the pelvic floor in preparation for delivery

1560: A pregnant client w mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects which prescription?

subcutaneous administration of heparin sodium 5000 unity daily

1536: A pregnant client asks the nurse about the type of exercises that are allowed during the pregnancy. The nurse would instruct the client that which is the safest exercise?

swimming

2981: The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?

syphilis

2285: A pregnant client is a gravida III, para O, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband, knowing that which instruction will assist in promoting family adaptation?

teaching the husband to perform passive ROM and provide back rubs for his wife

2284: The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action would the nurse take before the procedure to ensure fetal safety?

test the ultrasound equipment to ensure proper functioning

0229: The nurse is monitoring a client w mild gestational hypertension (GH). Which data indicate that GH is a concern?

the client complains of a headache and blurred vision

1487: The nurse is assisting in planning care for a client w a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?

the client exhibits no signs of fetal distress

1113: A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

the client is wearing knee-high hose

2982: The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?

the feelings of guilt that is often associated w grief

3430: The nurse is providing education to a client w gestational diabetes who was recently placed on insulin therapy. Which information would the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?

the insulin needs will increase

2358: A nursing student prepares a teaching plan for a pregnant client newly diagnosed w diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information?

to avoid exercise because of the negative effects on insulin production

2979: The nurse reinforces instructions to a pregnant client regarding the administration of iron. The nurse determines that the teaching is effective if the client states that she will take the iron w which food items?

tomato juice (foods containing ascorbic acid (vitamin C), such as tomato juice, may increase absorption of iron)

2427: A client in the prenatal clinic presents w a blood pressure reading of 140/90 mm Hg, which is an elevation from last month's reading of 114/66 mm Hg. Which additional s/s suggests to the nurse that the client has mild preeclampsia?

trace amount of protein

2924: The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic would be part of the teaching plan for this class?

travel precautions and use of shoulder seat belts

0200: The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse would tell the client that fetal circulation consists of which components?

two umbilical arteries and one umbilical vein.

1540: The nurse is reviewing the record of a pregnant client and notes that the PHCP has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?

violet bluish color of vaginal mucosa and cervix

3837: The nurse is collecting data from a pregnant client w a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where?

vulva

2281: A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which measure is appropriate to suggest to the client?

wear a perineal pad to the play

1103: A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

week 5

2883: The nurse is gathering data from a pregnant client about physiological risk factors. The nurse would be sure to obtain which priority data?

weight and height

2289: During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding indicates a serious nutritional disorder of pregnancy?

weight compared to last visit is a loss of 2.3 pounds

1064: A pregnant client in the third trimester of pregnancy w a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the PHCP and tells the client to call the PHCP if which occurs?

weight increases by more than 1 pound in a week

0196: The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse would make?

where fertilization occurs