OB FINAL 21
As part of caring for childbearing families, the nurse must be able to educate families regarding which topic?
Knowledge of reproductive anatomy and physiology
The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?
Longitudinal
A nurse is asked to auscultate the fetal heart sounds in a pregnant client. Which equipment is most appropriate when auscultating fetal heart sounds at the 12th week?
Doppler
A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply.
Establish a baseline of present health. Determine the gestational age of the fetus. Monitor for fetal development and maternal well-being. Identify women at risk for complications.
Which nursing intervention would best demonstrate evidence-based practice in maternal-child health care?
Family-centered pediatric care
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?
Fetal heart rate in relation to contractions
The nurse is teaching a group of women about the hormone that makes the ovum within the ovaries mature each month. Which hormone is responsible for stimulating the ovum?
Follicle-stimulating hormone
Fetal circulation differs from the circulatory path of the newborn infant. In utero the fetus has a hole connecting the right and left atria of the heart. This allows oxygenated blood to quickly pass to the major organs of the body. What is this hole called?
Foramen ovale
A client at 16 weeks' gestation comes to the office for a routine exam. At what location within the abdomen would the nurse anticipate the uterus to be found?
Halfway between the symphysis pubis and the umbilicus
During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as:
Hegar sign.
A nursing student is preparing a presentation illustrating the Human Genome Project. Which function will the student point out as being the primary focus?
Identification of human genes and functions
Which statement made by a nursing student would best indicate that her education on family-centered care was fully understood?
"Childbirth affects the entire family, and relationships will change."
The nurse is screening for potential exposure to toxoplasmosis. Which question is most appropriate?
"Do you have a cat in the house?"
The nurse is providing care for a pregnant client who has been given the necessary requisitions for laboratory work by the primary care provider. The client notices that the lab tests include testing for HIV and other sexually transmitted infections, and expresses alarm, stating, "I don't understand why the doctor would suspect that I've got these diseases." What is the nurse's most therapeutic statement?
"Every pregnant client is tested for these diseases; it doesn't necessarily suggest that the doctor suspects that you have them."
A nurse is providing education to a client with infertility concerns. Which statement by the client indicates appropriate understanding of the Spinnbarkeit Test?
"Halfway in my cycle I will need to check my cervical mucus to see if I can stretch it into long strands, indicating I am close to ovulating.
The nurse is assessing a client's risk for sexually transmitted infections. Which statement by the client would be cause for concern?
"I am unsure who the father of the baby is. I will be raising it alone."
The nurse instructs a pregnant client on the need to increase foods containing folic acid. Which client statement indicates that teaching has been effective?
"I will add spinach to my salad every evening."
The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective?
"I will need to take iron supplementation throughout my pregnancy even if I am not anemic."
After teaching a group of expectant mothers about how to best protect the fetus while in utero, which statement by a mother would best validate understanding of the teaching session?
"I will not take any medicines that the doctor has not prescribed without checking first."
Why is a Papanicolaou test done at the first prenatal visit?
It identifies abnormal cervical cells.
A young male asks the nurse at the clinic about what he can do to maintain his sperm production. The nurse would instruct him to take which action?
It is recommended that men wear boxer-style underwear.
The nurse-midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell sign. Which description illustrates this alteration?
The cervix softens.
Which client outcome during active and transitional labor is best? _
The client will practice breathing techniques during contractions.
The nurse is assisting a pregnant client who underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?
The fetal heart rate increases with activity and indicates fetal well-being.
The nurse is planning a class for nurses learning to teach early prenatal classes. Which statement indicates that teaching has been effective?
The goal of early prenatal care is to optimize the health of the woman and the fetus.
A client with a 28-day cycle reports that she ovulated on May 10. When would the nurse expect the client's next menses to begin?
May 24
The vagina is at risk for infection because of its location and because it opens to the outside of the body. What is a protective mechanism of the vagina to keep it from becoming infected?
Normal vaginal pH is acidic (4 to 5), which protects from infection.
A nurse is providing home care to several families who live in a community with limited resources. Which action is an example of how the nurse can best "nurse the community"?
Organize a free flu vaccination in the community.
A group of nursing students are preparing a presentation which will illustrate various components of the birthing process. When presenting the pelvis, the students should point out that it is often referred to as which term?
Passageway
The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?
Positive home pregnancy test
The nurse is preparing to teach a drug education class at a local elementary school. The nurse is focused on providing which type of care to the community?
Primary prevention
The alkaline fluids secreted by the prostate and Cowper glands serve what functions related to sperm? Select all that apply.
Provide nourishment of the sperm Protect the sperm from the acidic vaginal environment Enhance sperm motility
A parent tells you she found caring for her son at home very difficult at first but now has adjusted. What would be the most appropriate nursing diagnosis for this family?
Readiness for enhanced coping related to home care
A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?
Rest when possible with feet elevated at or above the heart.
The nurse is assessing a client at her first prenatal visit and reports her LMP started December 1. Which date will the nurse predict for the EDD?
September 8
A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?
Stop and walk every 2 hours.
An adolescent client asks the nurse about how the ovaries work. The nurse would include which information in her reply?
Storage of ova and maturation of them is one of the main functions of the ovaries.
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?
Take no extra measures; prepare for a standard labor.
The client is 32 weeks' pregnant and has been referred for a biophysical profile (BPP) after a nonreassuring nonstress test (NST). Which statement made by the client indicates that the nurse's explanation of the procedure was effective?
The BPP is an ultrasound that measures breathing, body movement, tone, and amniotic fluid volume.
The nursing student is preparing to complete the physical inspection of a female client's external reproductive organs. The mentor determines the student has successfully assessed this client based on documentation of which structures? Select all that apply.
perineum labia majora clitoris
Which client immunization titer is most important to assess and document in the prenatal record of the pregnant woman?
rubella
Because of high divorce rates and separations in recent years, there has been a significant increase in the family structure termed:
single-parent
A couple is arguing and bickering all the time. This couple has not told the children yet that they are planning to get a divorce. When the couple discusses this with the school nurse, the nurse shares that at this early phase, children likely experience what type of feelings?
take blame for their parents quarreling and try to behave better
What medication should the nurse advise a woman to discontinue prior to becoming pregnant because it will damage the developing dental and osseous tissue in the fetus?
tetracycline
Increased pigmentation on the face of some pregnant women is called:
melasma (chloasma)
Many changes occur in the body of a pregnant woman. Some of these are changes in the integumentary system. What is one change in the integumentary system called?
melasma (chloasma)
After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:
menstrual period.
The nurse advises a pregnant client to keep a small high-carbohydrate, low-fat snack at the bedside. The nurse should point out this will assist with which condition?
nausea and vomiting
A nurse is assessing a family with a married couple and their immediate biological children. How would the nurse document the description of this family?
nuclear
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? _
occiput
A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client?
on her side with the weight of the uterus on the bed
The nurse is advising a pregnant woman during her first prenatal visit regarding the frequency of future visits. Which schedule is recommended for prenatal care?
once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth
A 17-year-old client arrives for an annual examination and reports no changes since the last exam; however, the nurse assesses a positive Chadwick sign, slightly enlarged uterus, and subsequent positive urine pregnancy test. Which task should the nurse prioritize to assist this client who is denying any possibility that she is pregnant?
Accepting the pregnancy
A client at 10 weeks' gestation is reporting nausea and vomiting throughout the day. What interventions would the nurse recommend to this client? Select all that apply.
Eat small frequent meals. Avoid fried foods. Eat saltine crackers before getting out of bed.
A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?
Elevate the head of the bed.
A nursing instructor is teaching a class on the male reproductive system. The instructor determines the session is successful when the students correctly choose which functions of the bulbourethral glands' (Cowper glands) secretions? Select all that apply.
Enhance sperm motility Nourish sperm Protect sperm
A community-based nurse is assessing the needs of a family of four, which includes a physically challenged 9-year-old. Which activity would the nurse prioritize to be an advocate for this family?
Establish eligibility for assistive devices for child.
The nurse is counseling a young woman who has just entered her second trimester, after an uneventful first trimester. She tells the nurse, "It still doesn't seem real. It's just hard to believe that I will really have a baby." Which future events should the nurse point out that will help the young woman come to believe it is real? Select all that apply.
Feeling the baby kick Seeing an ultrasound image of the baby
The nurse is assessing a 16-year-old female on a routine well-child visit. Which assessment finding will the nurse predict this healthy female will report concerning her menstrual cycles?
Flow usually lasts 4 to 6 days.
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?
Meats
A client is at the clinic for her yearly physical and is found to be anemic. What information from her history would most likely be a contributory factor to this finding?
She reports that her menstrual cycle is irregular and often lasts 7 to 10 days.
A pregnant client at 24 weeks' gestation calls the clinic crying after a prenatal visit, where she had a pelvic exam. She states that she noticed blood on the tissue when she wiped after voiding. What initial statement by the nurse would explain this finding?
The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual.
The functions of the family are important in preserving our society with its beliefs, norms, and values. There are five major functions of the family unit; what is one of them?
giving and teaching emotional support
The nurse is participating in a poisoning prevention program. This activity is an example of which type of community-based nursing intervention?
health education program
A nurse is taking a history during a client's first prenatal visit. Which assessment finding would alert the nurse to the need for further assessment?
history of diabetes for 4 years
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
human chorionic gonadotropin (hCG)
A pregnant woman has a ruptured tubal pregnancy. What does the nurse anticipate the treatment will be?
immediate surgical removal of the pregnancy and affected tube
A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor?
increase in frequency of the contractions
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:
latent phase of the first stage.
Assessment for surfactant level is a primary estimation of fetal maturity. The purpose of surfactant is to:
prevent alveoli from collapsing on expiration.
Assessment for surfactant level via lecithin/sphingomyelin (L/S) ratio in the amniotic fluid is a primary estimation of fetal maturity. The purpose of surfactant is to:
prevent alveoli from collapsing on expiration.
During a family assessment, it is identified that the mother is unemployed but stays at home to prepare meals, monitor medication doses, and comfort the children with emotional issues. The father works outside of the home and pays the bills. Which terms should the nurse use to document the role of the father in this family? Select all that apply.
provider financial manager
The OB nursing instructor is talking with students about the sexual response cycle. As they are studying the content, they become aware that there are four phases in the sexual response cycle and identify them as which of the following? Select all that apply.
resolution excitement climax plateau
The placenta is the site where antibodies in the mother's blood pass into the fetal circulation. These antibodies give passive immunity to the fetus for several common childhood diseases. There are some infections for which the mother does not provide antibodies to the fetus. What infection is the fetus not protected from?
rubella
The nursing instructor is teaching a group of nursing students about the menstrual cycle. The instructor determines the session is successful when the students correctly choose which action as responsible for the increased thickness of the endometrium?
the increasing level of estrogen
One type of medicine a client on home care receives could be given with any of the following schedules. Which of the following would be most effective in helping compliance?
three times a day at 10 am, 2 pm, and 10 pm
The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?
ultrasound picture of her fetus
The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting?
separation of the muscles of the abdominal wall
The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time?
urinary frequency
In OB class, the nursing instructor is discussing the female reproductive anatomy. In order to understand the anatomy and function of the uterus, the instructor explains that there are four sections in the uterus. Which of the following are sections of the uterus? Select all that apply.
uterine isthmus fundus cervix corpus
A nurse is assessing a pregnant client. Which of the following would the nurse document as an abnormal finding in a pregnancy?
visual changes
A client who has just given a blood sample for pregnancy testing in the health care provider's office asks the nurse what method of confirming pregnancy is the most accurate. The nurse explains the difference between presumptive symptoms, probable signs, and positive signs. What should the nurse mention as an example of a positive sign, which may be used to diagnose pregnancy?
visualization of the fetus by ultrasound
During a clinical rotation at a prenatal clinic, a client asks a nurse what causes certain birth defects. The nurse replies that they can be caused by teratogens. What does the severity of the defects depend on? Select all that apply.
when during development the conceptus is exposed to the teratogen the particular teratogen to which the fetus is exposed
A fertilized ovum is known as which structure?
zygote
A client at 6 weeks' gestation asks if she can listen to the fetal heart sounds. The nurse informs the client that fetal heart sounds cannot be heard with a Doppler until when?
10 to 12 weeks
The case manager is looking over the inpatient census on the floor to determine which client would be the best candidate for discharge with home health care follow-up. Which client would the case manager recommend to the practitioner for discharge?
10-year-old boy with an infected laceration on his leg who has been treated with IV antibiotics for 3 days.
A client comes to the clinic for her usual prenatal check up. The nurse measures the fundal height at 24 cm. What is the estimated length of her gestation?
24 weeks
Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks gestation.
4, 1, 1, 1, 1
A couple comes to the clinic for preconception counseling and care. As part of the visit, the nurse teaches the couple about fertilization and initial development, stating that the zygote formed by the union of the ovum and sperm consists of how many chromosomes?
46
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks' pregnant. The nurse would expect this woman's heart rate to be approximately:
85 beats per minute.
Which physician is known as the "Father of Pediatrics"?
Abraham Jacobi
A nurse is reviewing the statistical outcomes related to fetal deaths nationwide and notes that the numbers have changed over the last several decades. The best explanation would be:
improved prenatal care has reduced the numbers of fetal deaths.
The biggest benefit of health care provided in the home is:
inclusion of the entire family in health care planning and provision.
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?
increase even if relaxing and taking a shower
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?
increased white blood cell count
An adolescent at 8 weeks' gestation is at her first prenatal visit. During the health history interview, the nurse asks the client, "Are you afraid of anyone?" What is the nurse assessing with this question?
intimate partner violence
What medication can the nurse tell the client that, when taken as directed, is nonteratogenic and safe during pregnancy?
acetaminophen
A woman is at 20 weeks' gestation. The nurse would expect to find the fundus at which area?
at the level of the umbilicus
The nurse understands that the maternal uterus should be at what location at 20 weeks' gestation?
at the level of the umbilicus
A community-based nurse has a different set of skills than those of counterparts who work in a hospital. Community-based nurses also face unique issues and challenges. What is one of the unique aspects of community-based nursing?
autonomous action
During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. This occurs about 4 or 5 times during the testing period. The nurse interprets this as:
reactive pattern.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?
Complete cervical dilation and time of fetal birth
A home care nurse is visiting a pregnant client from the Arab culture. During the health history the husband frequently answers questions for the client. How should the nurse respond?
Continue with the health history.
The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?
Darkened breast areolae
The time in a woman's life when she loses the capability to reproduce is called menopause. Menopause does not occur all at once, but over a period of time that differs from woman to woman. There is, however, an average age when menopause occurs. What is this average age?
between 47 and 55 years
After teaching students about different family structures, the instructor determines that the session was successful when the students identify which of the following as comprising a blended family. Select all that apply.
birth parent non-birth parent stepchildren birth children
Which is the most important nursing assessment of the mother during the fourth stage of labor?
bleeding
A client has learned that she is 4 weeks' pregnant. The client states, "I don't see how that's possible. I'm sure that I had some bleeding almost exactly 4 weeks ago." The nurse should educate the client about what phenomenon?
bleeding that sometimes accompanies implantation
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply.
breast changes amenorrhea morning sickness
During a prenatal visit, the nurse inspects the skin of the client's abdomen. Which would the nurse identify as an abnormal finding?
bruising
Before beginning the initial prenatal examination, a nurse should instruct a client to complete what procedure before undressing?
clean-catch urine
The nursing instructor is preparing a class presentation covering the various hormones and their functions during pregnancy. The instructor determines the class is successful when the class correctly matches which function with hCG?
continues progesterone production by corpus luteum
A nursing student is explaining to a newly pregnant woman what happens during each stage of fetal development. At which stage does the nurse inform the woman that the lungs are fully shaped?
end of 16 weeks
A group of nursing students are preparing a presentation for a health fair illustrating what happens to the body during pregnancy. Which structure will the students point out is influenced the most by hormones to prepare for conception?
endometrium
The family functions as the oldest and most basic social unit in society. What is the primary purpose of the family?
ensure survival
A school nurse who is teaching a health course at the local high school is presenting information on human development and sexuality. When talking about the role of hormones in sexual development, which hormone does the nurse teach the class is the most important for developing and maintaining the female reproductive organs?
estrogen
The nurse is conducting a presentation for a young adult community group about fetal development and pregnancy. The nurse determines that the teaching was successful when the group identifies that the sex of offspring is determined at which time?
at fertilization
A nurse is providing care to a client and actively involves the client's family members in the care planning and implementation, dealing with the client and family as a unit. The nurse is engaging in:
family-centered care
Charlene McCoy, who has several children already, reports for a first prenatal visit. She seems preoccupied and withdrawn, and she makes consistently negative remarks about the pregnancy. Reviewing her records, you note that she is receiving a serotonin reuptake inhibitor. What should you do?
Alert the RN or health care provider.
The nurse is reviewing the structure and function of various organs in the female reproductive system. Which information should the nurse include about the ovum in the review with the client?
All the ova a female will ever have are present at birth.
When integrating the principles of family-centered care into the birthing process, the nurse would base care upon which belief?
Birth results in changes in relationships
After completing an assessment, the nurse examines the information to develop a wellness diagnosis for the client to identify which potential goal?
The potential for improvement in health
A client asks the nurse about how the testes function in reproduction. Which is the nurse's best reply?
The testes serve as the production center for sperm.
The nurse at a family planning clinic is meeting with a young couple who have decided not to have any children after they marry since they are both bringing children into the relationship. The nurse will document this as which type of family structure?
Blended family
A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?
Blood is trapped in the vena cava in a supine position.
During an exam, the nurse notes that the blood pressure of a client at 22 weeks' gestation is lower, and her heart rate is 12 beats per minute higher than at her last visit. How should the nurse interpret these findings?
Both findings are normal at this point of the pregnancy.
Which information provided by a client would be considered a presumptive sign of pregnancy?
Breast tenderness
The nurse is teaching a non-English speaking primigravida about the most common type of fetal presentation. Which presentation will the nurse prepare?
Cephalic presentation using preprinted materials in her language
The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?
Continue this as long as she enjoys it.
The nurse is reviewing the functions of the ovaries, uterus, clitoris, and vagina with a group of nursing students. What would be the correct response by a nursing student about the function of the ovaries?
They produce female gametes or ova and secrete female sex hormones.
When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?
fundal height measurement
During a routine prenatal visit, a client at 36 weeks' gestation states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. The nurse would prioritize developing a plan of care identifying interventions to promote which area?
gas exchange
A nursing student studying reproduction identifies which of the following statements to be correct?
Twenty-two of the 23 pairs of chromosomes are autosomes and the remaining pair is the sex chromosomes.
The nurse is conducting a comprehensive initial assessment of a pregnant client during a prenatal visit. When assessing the client's social history, what questions should the nurse include? Select all that apply.
"What do you currently do for employment?" "Do you currently use tobacco?" "Who do you have in your life who can support you?"
A client is about 16 weeks' pregnant and is concerned because she feels her "abdomen" contracting. She calls the primary care provider's office and speaks to the nurse. What is the nurse's most appropriate response to this client's concern?
"What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy."
After teaching a health education class on the female reproductive cycle, the nurse determines that the teaching was effective when the group identifies which phase as belonging to the ovarian cycle?
follicular phase
The nurse is caring for a client who is a primagravida. Which statement is best to improve the client's psyche?
"You are doing a great job"
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?
frank
The nurse is teaching breastfeeding to a group of clients on the postpartum unit. The nurse recognizes that this action represents which component of the nursing process?
implementation
A woman comes in for her annual gynecological examination and informs the nurse that she is going to try and become pregnant. She asks the nurse when the best time in the month is to become pregnant. What is the best response by the nurse?
"3 days before until 2 days after ovulation."
A mother has come to meet with local school officials regarding admission of her child with spina bifida. The child requires catheterizations several times a day and the mother is requesting information on admission of the child for school and what accommodations can be made for the child's health care needs. What is the best response to the mother?
"Your child may be mainstreamed into a regular classroom and assisted with catheterizations by the school nurse."
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged."
During a prenatal visit, a pregnant woman says, "I know the amniotic fluid is important, but can you tell me more about it?" When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include?
"This fluid acts as a cushion to help to protect your baby from injury."
A woman tells the nurse that she is going to use a home pregnancy test to determine whether she is pregnant. Which precautions should the nurse give her?
Arrange for prenatal care if the test is positive.
The nurse is performing a cultural assessment of a family that has a child hospitalized for leukemia. What is the best technique for providing culturally competent care for this family?
Ask the family about their culture and listen.
The nurse is assessing a child of a different cultural background. Which nursing action should the nurse prioritize when providing nursing care?
Ask the family for input into their care based on their cultural beliefs.
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
Ask the woman to describe why she believes that she is in labor.
The nursing instructor is teaching a session comparing the various steps of the nursing process. The instructor determines the session is successful when the students correctly choose which step as the first one?
Assessment
A nurse who specializes in maternal and child health care performs many varied functions in diverse settings over the course of a year. Which action would be outside the nurse's scope of practice?
Assist in the treatment and recovery of a woman with ovarian cancer.
Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.
Vaginal rugae stretch and smooth out The cervix dilates to 10 cm The cervix softens
Positive signs of pregnancy are diagnostic, meaning nothing else can elicit that sign except pregnancy. What is the earliest positive sign of pregnancy?
Visualization of the gestational sac or fetus
Suppose a client has several large dogs that you are concerned have fleas. Where would you plan to sit to interview the client during a home visit?
a kitchen chair
A client makes an appointment at the prenatal clinic because she thinks she might be pregnant. Which assessment is a probable sign of pregnancy?
a positive pregnancy test
The fluid-filled, inner membrane sac surrounding the fetus is which structure?
amnion
What is the major concern for a lactose intolerant woman who is pregnant?
calcium deficiency
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?
degree of thinning
While on a mission trip, a nurse works with a family who has one husband and several wives. How would this family be documented?
polygamous family
After teaching a class on the stages of fetal development, the nurse determines that the teaching was successful when the group identifies which stages? Select all that apply.
pre-embryonic embryonic fetal
The nurse is assessing a woman who is pregnant for the first time. Which of the following terms applies to this client?
primigravida
A child is being cared for in the home by its mother. When making a home visit the community health nurse notes that the mother understands the positive aspects of home health care. Which statement made by the mother best illustrates one of the positive aspects of home health care?
"I can do my child's care since you taught the procedure to me."
A home care nurse is visiting with a teenage client on home care during cancer treatments. Which statement by the client's mother warrants intervention by the home care nurse?
"I don't let her drink too many fluids since the bathroom is downstairs."
The nurse teaches a pregnant client the manifestations associated with complications while pregnant. Which statement indicates that additional client teaching is needed?
"Pain with urination is expected during pregnancy."
The pediatrician's nurse is educating the mother of a young preadolescent girl. She advises the mother that puberty is marked by the appearance of secondary sexual characteristics and maturation of the reproductive organs. The mother asks the nurse when this will happen. The nurse's reply is based on her knowledge that puberty usually occurs between:
10 and 14 years of age.
A 24-year-old childcare worker comes to the clinic for her first prenatal visit. She cannot remember when her last period was but thinks it was between 2 and 5 months ago. When she began gaining weight and feeling "odd" she did a home pregnancy test, which was positive. She states she felt fetal movements about 1 week ago. She has had no nausea, vomiting, fatigue, or fevers. Past medical history is remarkable for irregular periods. She has been dating the same man for 1 year and says they did not use condoms. Examination reveals an overweight young woman who appears her stated age. Head, eyes, ears, nose, throat, neck, thyroid, cardiac, and pulmonary examinations are unremarkable. The client's abdomen is nontender with normal bowel sounds, and the gravid uterus is palpated to the level of the umbilicus. Fetal tones are easily found with Doptone; with the fetoscope a faint heart rate of 140 is audible. By speculum examination the cervix is bluish; by bimanual examination the cervix is soft. Papanicolaou test, cultures, and blood work are pending. The nurse gives the client her due date and how far along she is based on clinical findings. An obstetric ultrasound to confirm her dates is ordered. Based only on the clinical examination findings, how many weeks pregnant did the nurse tell this client she was?
18 to 20 weeks
The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize?
Be certain she is aware of potential complications.
A 13-year-old client who is newly diagnosed with type 1 diabetes is being discharged home with home care follow-up. What is the most appropriate goal for the nurse to select related to the nursing diagnosis of Health-Seeking Behaviors related to Skills Needed to Continue Home Care?
Client will self-administer insulin injections using appropriate technique.
A nursing instructor is explaining the stages of fetal development to a group of nursing students. The instructor determines the session is successful after the students correctly choose which time period as representing the pre-embryonic stage?
From fertilization to the end of the second week after fertilization
The nurse is reviewing the functions of the ovaries, uterus, clitoris, and vagina with a group of high school students. What would be the best response by a high school student about the function of the vagina?
It receives sperm, provides an exit for menstrual flow, and serves as the birth canal.
The nurse is reviewing the functions of the ovaries, uterus, clitoris, and vagina with a group of nursing students. What would be the best response by a nursing student about the function of the uterus?
It receives the fertilized ovum and provides housing and nourishment for a fetus.
The opening up of hospital visiting policies for children and families likely resulted from the work of which individual?
John Bowlby
The nurse is caring for a client with a G=5, T=0, P=3, A=1, L=3 obstetric history. The nurse is most correct to state which interpretation?
The client has had difficulty reaching full term.
Which description is best when documenting an accurate client contraction?
The client's contractions are 5 minutes apart and last 45 seconds.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?
The frequency of the contractions is every 5 minutes.
The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The intestines are displaced by the growing fetus.
The nurse at a health fair is teaching about the various changes of puberty. Which sequence of events will be best for the nurse to present when illustrating pubertal changes in females?
breast budding, appearance of pubic hair, menarche
Which body system is most affected throughout the embryonic and fetal period by teratogens?
central nervous system
Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to:
detect fetal heart sounds with a Doppler.
Which of the following may be a strength of the single-parent type of family?
development of a special parent-child relationship
The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first?
development of breast buds
During an assessment, a client who is 5 months pregnant tells the nurse that she has to change her diet because she is just becoming too fat. Which nursing diagnosis should the nurse use to guide interventions for the client at this time?
disturbed body image
A 38-year-old client presents to the clinic desiring to get pregnant. She reports she had a tubal ligation in her early 20s after two babies and a divorce. After learning that the client recently underwent a reversal of the tubal ligation, the nurse will warn the client of which potential risk?
ectopic pregnancy
During which stage of fetal development is exposure to teratogens most damaging?
embryonic stage
A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to:
encourage her to identify someone that she can talk to and share the pregnancy experience.
A married couple has 3-year-old twins. They own a dog. The father's mother lives with them. The father is a professor; the mother has resigned from her position as a legal secretary to be the children's primary caregiver. Which type of family does this represent?
extended
What is a positive sign of pregnancy?
fetal movement felt by examiner
A woman is confused after finding out the ultrasound results predict a different due date for the birth of her baby. Which factor should the nurse point out is most likely the reason for the miscalculation of the fetal age?
mistaking implantation bleeding for last menstrual period (LMP)
