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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 pregnant client.
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 Rh sensitization when the client makes which statement?
"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus.
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
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be appropriate?
"Do you plan to have any other children?"
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 a understanding of the implications of the client's symptoms? 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?"
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
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
The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?
28 cm
A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?
Abdominal pain
A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing?
Fetal heart rate of 180 beats per minute
The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?
Fresh spinach
The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document the GTPAL for this client as which?
G = 2, T = 1, P = 0, A = 0, L = 1
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 health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation?
Increased blood volume of the mother during pregnancy
During a prenatal visit of a client diagnosed with placenta previa, the health care provider defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk?
Initiating severe hemorrhage
The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone 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.
The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use?
Palpate for uterine contractions at the same time as the client.
The nurse caring for a client with 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
The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?
Pregnancy greatly increases the risk of malnourishment for the mother.
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
A pregnant client is a gravida III, para 0, 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 range of motion and provide back rubs for his wife
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.
The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?
The bladder must be full during the exam.
The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?
The client complains of a headache and blurred vision.
The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that which is a characteristic of this type of pelvis?
The most favorable for labor and birth
The nursing 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."
A client at 32 weeks of gestation with 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."
The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which would indicate successful learning?
"The iron is needed for the red blood cells."
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 (Pitocin) or by nipple stimulation."
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which?
Two umbilical arteries and one umbilical vein
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
A 23-year-old client develops melasma during pregnancy. The nurse notes that the client has started wearing very heavy makeup. The client tells the nurse that she is fearful that her mate will reject her and that she has decreased her social engagements drastically because of this change. The nurse determines that the client is experiencing which problem?
Concern about her appearance
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
The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?
Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.
The nurse is working with a woman who has just been diagnosed with 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.
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 with this diagnosis? Select all that apply.
Vaginal bleeding Excessive vomiting No fetal heart activity Larger than normal fetus size for gestational age Elevated levels of human chorionic gonadotropin (HCG)
The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area?
Vulva
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
The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?
July 27, 2017
The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which area?
Just above the symphysis pubis
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 should make?
Are where fertilization occurs
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.
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
Ballottement, Chadwick's sign, Uterine enlargement, Braxton Hicks contractions
While assisting with 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?
Compression of the vena cava
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 this pregnancy?
She has a history of chronic hypertension.
The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?
A diet that is high in fluids and fiber to decrease constipation
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 health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?
A softening of the cervix
The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?
Gravida II, para I
The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?
Monitoring fetal movement
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
