NUR 230 Exam 1 practice

A client at 39 weeks of gestation calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse?

"Fetal movements do not decrease as a person nears term; therefore, you need to be seen by your primary health care provider for further evaluation." Submit

The nurse is assisting the primary health care provider to perform Leopold's maneuvers on a pregnant client. Which action would the nurse perform before the procedure?

- Ask the client to urinate - An empty bladder contributes to a client's comfort during this examination. Often Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.

The nurse provides teaching on how to relieve discomfort to a client in the second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching?

"When I get home, I need to lie on the floor with my legs elevated on a couch and turn my hips and knees at right angles."

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client?

- Assess for signs and symptoms of labor * As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor

A pregnant client calls the clinic and tells the nurse about experiencing leg cramps and is awakened by the cramps at night. Which activity would the nurse tell the client to perform when the cramps occur?

- Dorsiflex the foot while extending the knee - Leg cramps occur when pregnant client stretches leg and plantar flexes foot. Dorsiflexing the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action would the nurse take to determine fetal heart sounds accurately?

- Palpating the maternal radial pulse while listening to the FHR *The nurse would simultaneously palpate maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR.

Findings that indicate to nurse that client is beginning second stage of labor

- The cervix is dilated completely - The spontaneous urge to push is initiated from perineal pressure.

Gestational diabetes

- can result in delayed lung maturity and complications - carrying baby until full term is the goal - nurse would discuss nonstress testing procedures, plan for nutritional counseling, and plan for delivery

DIC

- is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. - Dead fetus syndrome is considered a risk factor for DIC. - Severe preeclampsia is considered a risk factor for DIC; a mild case is not. - Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

Rubella titer

- is performed to determine immunity to rubella - If the client's titer is less than 1:8, the pregnant client is not immune. - A retest during pregnancy is prescribed, and the client is immunized postpartum if they are not immune.

The nurse is reviewing the medical record of a client scheduled for a weekly prenatal appointment. The nurse notes that the client has been diagnosed with mild preeclampsia. Which interventions would the nurse include in planning nursing care for this client?

Assess blood pressure Check urine for protein Assess deep tendon reflexes Teach the importance of keeping track of a daily weight.

Negative contraction stress test

A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period.

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Based on the last normal menstrual period, they are 8 weeks' gestation. Appropriate physical assessments are completed. Which findings are anticipated to be present at this time?

A softening of the cervix Bluish discoloration of the vaginal tissue The presence of human chorionic gonadotropin in the urine

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin

The nurse correctly identifies fetal distress when evaluating which of the following assessments? Fetal heart tones (FHT) 115-124 with occasional FHT to 140-144 for 15-20 seconds. Fetal heart tones (FHT) 115-118 with no periodic changes.

Fetal heart tones (FHT) 115-118 with no periodic changes.

The labor room nurse assists with the administration of a lumbar epidural block. How would the nurse check for the major side effect associated with this type of regional anesthesia?

Monitoring the client's blood pressure

There is a need to complete a BPP by obtaining a

NST

The clinic nurse is instructing a first-trimester pregnant client about nutrition. The nurse would determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the pregnant client

The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time?

The fetus is approximately 42 to 48 cm long.6The lecithin-sphingomyelin (L/S) ratio is greater than 2:1.

Risk factors that increase a client's risk for dysfunctional labor (labor dystocia)

advanced age being overweight electrolyte imbalances previous difficulty with fertility uterine overstimulation with oxytocin short stature prior version masculine characteristics uterine abnormalities malpresentations and position of the fetus cephalopelvic disproportion maternal fatigue dehydration fear administration of an analgesic early in labor use of epidural analgesia

During a precipitous labor, when the infant's head crowns, the nurse instructs the client to

breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down.

Bradycardia or late or variable decelerations indicate

fetal distress and the need to discontinue the oxytocin.

Biophysical profile

is done at 32 to 36 weeks' gestation

Administration of oxytocin for induction

is not a risk factor for labor dystocia

An elevated maternal serum alpha-fetoprotein (MSAFP)

would be followed up with more specialized testing to determine whether a neural tube problem exists.