NCLEX RN Examination Maternity: Antepartum
The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching? 1."It is best that I rest on my left side to promote blood return to the heart." 2."I need to avoid excessive weight gain to prevent increased demands on my heart." 3."I need to try to avoid stressful situations because stress increases the workload on the heart." 4."During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection.
"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Resting should be done while lying on the left side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased workload on the heart, and the client should be instructed to avoid stress.
A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs? 1."My weight gain is not important." 2."I should avoid stressful situations." 3."I should rest by lying on my back." 4."There is no restriction on people who visit me."
"I should avoid stressful situations." Stress causes increased heart workload, and the client should be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return and avoid supine hypotension. To avoid infections, individuals with active infections should not be allowed to visit the client. Otherwise, restrictions are not required.
The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions? 1."Iron supplements may give me constipation." 2."All foods with protein lack iron and should be avoided." 3."The iron is best absorbed if taken at breakfast with some food." 4."My body has all of the iron it needs, and I don't need to take supplements.
1 ."Iron supplements may give me constipation." Iron is needed both to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and the hematocrit level. This is a normal adaptation and is known as physiological anemia of pregnancy. Therefore, supplements are needed. Iron supplements usually cause constipation. One food source of protein is meats and are an excellent source of iron. Iron is best absorbed if taken on an empty stomach.
During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? 1."Diet and insulin needs change during pregnancy." 2."I will plan my diet based on the results of urine glucose testing." 3."I will need to eat 600 more calories every day because I am pregnant." 4."I can continue with the same diet as before pregnancy, as long as it is well balanced."
1. "Diet and insulin needs change during pregnancy." The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. An increase of 600 calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the second and third trimesters, insulin needs increase.
During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? 1.Maternal infection 2.Gestational hypertension 3.Gestational diabetes mellitus 4.Consumption of recent high-sugar snack
1. Maternal infection The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to approximately 110 to 160 beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes, and consuming a high-sugar diet may affect the fetal heart rate but are not the most likely causes.
A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 37.2º C (99º F). The nurse plans care based on which interpretation? 1.The woman requires further evaluation for preterm labor. 2.The woman is suffering from an intestinal bacterial infection. 3.The woman is exhibiting signs and symptoms of gestational hypertension. 4.The woman needs instruction on pelvic tilts to decrease her lower back pain.
1. The woman requires further evaluation for preterm labor. Classic signs and symptoms of preterm labor include lower abdominal cramping, possibly accompanied by diarrhea; dull and intermittent low back pain; painful menstrual-like cramps; suprapubic pain or pressure; pelvic pressure or heaviness; urinary frequency; change in character and amount of vaginal discharge; and rupture of amniotic membranes. Early recognition of preterm labor is essential, so interventions such as tocolytic therapy and administration of antenatal glucocorticoids can be initiated; therefore, further evaluation of the cervix, membrane status, uterine activity, and fetal heart rate is necessary to determine if the client is in preterm labor (the correct option). The client's temperature is only slightly elevated, and her diarrhea presents in addition to the signs and symptoms of preterm labor, so option 2 can be eliminated. The client is not exhibiting signs of gestational hypertension, so therefore eliminate option 3. Because the client has additional complaints that may possibly relate to preterm labor, instruction on pelvic tilts to decrease back pain is irrelevant at this time, so therefore eliminate option 4.
In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections? 1.Establish a therapeutic relationship. 2.Use specific closed-ended questions. 3.Omit these types of questions because they are highly personal. 4.Apologize for the embarrassment that these questions will cause the client.
1.Establish a therapeutic relationship The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned, purposeful communication that focuses on specific content. The remaining options are incorrect and would not lend themselves to eliciting accurate information from the client.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.Proteinuria. 2.Hypertension 3.Low-grade fever 4.Generalized edema 5.Increased pulse rate 6.Increased respiratory rate
1.Proteinuria. 2.Hypertension The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1.The client is a 35-year-old primigravida. 2.The client has a history of cardiac disease. 3.The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4.The client is a 20-year-old primigravida of average weight and height.
2 The client has a history of cardiac disease. Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1.The client is a 35-year-old primigravida. 2.The client has a history of cardiac disease. 3.The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4.The client is a 20-year-old primigravida of average weight and height.
2. The client has a history of cardiac disease. Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.
The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 1.Avoid wearing a bra. 2.Wash the breasts with warm water and keep them dry. 3.Wear tight-fitting blouses or dresses to provide support. 4.Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.
2. Wash the breasts with warm water and keep them dry. The pregnant client should be instructed to wash the breasts with warm water and keep them dry. The client should be instructed to avoid using soap on the nipples and areolar area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses cause discomfort. The client is instructed to wear soft-textured clothing to decrease nipple tenderness and to use breast pads inside the bra to prevent leakage through the clothing if colostrum is a problem
The nurse should make which statement to a pregnant client found to have a gynecoid pelvis ? 1."Your type of pelvis has a narrow pubic arch." 2."Your type of pelvis is the most favorable for labor and birth." 3."Your type of pelvis is a wide pelvis, but it has a short diameter." 4."You will need a cesarean section because this type of pelvis is not favorable for a vaginal deliver
2."Your type of pelvis is the most favorable for labor and birth." A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? 1.Age 35 years 2.History of syphilis 3.History of genital herpes 4.History of diabetes mellitus
2.History of syphilis Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion, although the presence of active lesions at the time of birth presents concerns. Maternal age greater than 40 years and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations, not abortions.
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1.Bed rest as a necessary preventive measure may be prescribed. 2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.
2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 5.Thromboembolism stockings or sequential compression devices may be prescribed. The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, will likely be prescribed due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.
A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicate a need for further teaching? Select all that apply. 1.The client is wearing sneakers. 2.The client is wearing knee-high nylon stockings. 3.The client is wearing flat shoes with rubber soles. 4.The client is wearing pants with an elastic waistband. 5.The client is wearing sweatpants with snug elastic ankle bands.
2.The client is wearing knee-high nylon stockings. 5.The client is wearing sweatpants with snug elastic ankle bands. Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing such as knee-high stockings or snug elastic ankle bands impedes venous return from the lower legs and thus places the client at higher risk for developing varicosities. Clients should be encouraged to wear pantyhose or support hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize the risk for falls. Pants with an elastic waistband are comfortable and are not constricting.
During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention? 1.Notify the primary health care provider (PHCP). 2.Plan to refer the client for ultrasound testing. 3.Document findings in the electronic health record. 4.Schedule the client for a return appointment in 1 week for reassessment.
3. Document findings in the electronic health record. At 20 weeks' gestation, the fundus can be palpated at the umbilicus, the expected location. Because the assessment finding is normal, documentation of the finding should be the next step. Information will be shared with the PHCP, but since the finding is normal there is no urgency to do this. A normal assessment finding does not need to be followed by an ultrasound or an extra prenatal visit.
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1.Contact the primary health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Inform the client that these contractions are common and may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a preterm labor condition
3. Inform the client that these contractions are common and may occur throughout the pregnancy. 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 pregnancy, there is no reason to notify the primary health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1."It connects the pulmonary artery to the aorta." 2."It is an opening between the right and left atria." 3."It connects the umbilical vein to the inferior vena cava." 4."It connects the umbilical artery to the inferior vena cava."
3."It connects the umbilical vein to the inferior vena cava." The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. 1."You should avoid all school-age children during pregnancy." 2."There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3."You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." 4."Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester.
3."You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information.
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1.Strict bed rest is required after the procedure. 2.Hospitalization is necessary for 24 hours after the procedure. 3.An informed consent needs to be signed before the procedure. 4.A fever is expected after the procedure because of the trauma to the abdomen
3.An informed consent needs to be signed before the procedure. Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the primary health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.
A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 1. 5 weeks 2. 9 weeks 3. 13 weeks 4. 18 weeks
4. 18 weeks The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until 18 weeks' gestation or later, as she has no prior experience and the uterus has not been previously stretched during pregnancy adaptation. The first recognition of fetal movement is called quickening.
The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation ? 1."I don't like my figure anymore. My clothes are all too tight." 2."I don't like my breasts anymore. These silver lines are ugly." 3."I don't like my stomach anymore. That brown line is disgusting." 4."I don't like my face anymore. I always look like I have been crying.
4. I don't like my face anymore. I always look like I have been crying In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent.
The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? 1.Milk 2.Yogurt 3.Bananas 4.Leafy green vegetables
4. Leafy green vegetables Leafy green vegetables are rich in folate (folic acid). Milk and yogurt supply calcium; bananas provide potassium.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1."It connects the pulmonary artery to the aorta." 2."It is an opening between the right and left atria." 3."It connects the umbilical vein to the inferior vena cava." 4."It connects the umbilical artery to the inferior vena cava."
It connects the umbilical vein to the inferior vena cava. The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.
The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. 1.Viruses 2.Bacteria 3.Nutrients 4.Antibodies 5.Medications
Viruses Nutrients Antibodies Medication Large particles such as bacteria cannot pass through the placenta, but viruses, nutrients, medications, antibodies, and recreational drugs can pass through the placenta and potentially affect the fetus. Metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them.