Practice test questions and rationales
When assessing the psychological adjustment of an 8 week gravida, which of the following would the nurse expect to see signs of?
-ambivalence
A pregnant client is lactose intolerant, which of the following foods could t his woman consume to meet her calcium needs?
-turnip greens
At 20 weeks gestation, where would a nurse expect to feel the fundal height?
-umbilicus
The nurse is evaluating the 24 hour dairy intake of four gravid clients. Which of the following clients consumed the highest number of dairy servings during day 1? The client who consumed:
-1 cup yogurt, 8 oz chocolate milk, 1 cup cottage cheese, and 1 1/2 oz of hard cheese rationale: each is equal to 1 dairy serving
A client is in the 10th week of her pregnancy. Which of the following symptoms would the nurse expect the client to exhibit?
-urinary frequency -diarrhea rationale:organs become confined w/in the bony pelvis and the enlarging uterus prevents the bladder from expanding w/ large quantities of urine thus creating the need to urinate more
A client is 35 weeks gestation, which of the following findings would the nurse expect to see?
-use of three pillows for sleep comfort
A vegan is being counseled regarding vitamin intakes, it is essential that this woman supplements which of the following B vitamins?
-vitamin B12 rationale: found almost exclusively in animal products
The nurse is interviewing a 38 week gestation Muslim woman. Which of the following questions would be inappropriate for the nurse to ask?
-What do you plan to name the baby? rationale: traditional muslim couples won't tell anyone the baby's name until they go thru the official naming ceremony
A nurse is discussing the serving sizes in the grain food group w/ a new prenatal client. Which of the following foods equals 1 oz serving size from the grain?
-1 slice of bread -1 tortilla -1 cup dry cereal
Which of t he following choices can the nurse teach a prenatal client is equivalent to one 2 oz protein serving?
-2 eggs rationale: equal to 2 oz of protein serving
A third trimester client is being seen for routine prenatal care. Which of the following assessments will the nurse perform during the visit?
-BP -FHR -urine protein
A client informs the nurse that she is "very constipated" which of the following foods would be best for the nurse to recommend to the client?
-celery rationale: high fiber food
Which of the following developmental features would the nurse expect to be absent in a 41 week gestation fetus?
-lanugo rationale: infant is post-term
A woman confides in the nurse that she practices pica, which of the following alternatives could the nurse suggest w/ this behavior?
-replace ice w/ frozen fruit juice rationale: although high in sugar frozen fruit juice contains vitamins
The nurse takes a 31 week gestation client to lie on the examining table during a prenatal exam. What position should the client be placed?
-semi fowlers rationale: it reduces dyspnea
A woman tells the nurse that she would like suggestions for alternate vitamin C sources because she isn't very fond of citrus fruits. Which of the following suggestions is appropriate?
-strawberries and potatoes
A gravida's fundal height is noted to be at the xiphoid process, the nurse is aware that which of the following fetal changes is likely to be occurring at the same time in the pregnancy?
-surfactant is formed in the fetal lungs rationale: fully formed by 36 weeks
A woman is planning to become pregnant. Which of the following actions should be considered to take before stopping birth control?
-take daily multivitamins -see a medical Dr -smoking cessation
A client asks the nurse "Could you explain how the baby's blood and my blood separate at delivery?" Which of the following responses is appropriate for the nurse to make?
-the blood actually never mixes, your blood supply and the baby's blood supply are completely separated rationale: separated by membrane
A woman asks the nurse about the function of amniotic fluid. Which of the following statements by the woman indicates that the teaching was successful?
-the fluid cushions the fetus from injury -the fluid enables the fetus to grow -the fluid provides the fetus w/ a stable thermal environment -the fluid enables the fetus to practice swallowing
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal exam. How should the nurse explain what the nurse midwife means by ballottement?
-the nurse midwife felt the baby rebound after being pushed
After nutrition counseling, a woman G3 P1101, proclaims that she certainly can't eat any strawberries during her pregnancy. Which of the following is the likely reason for this statement?
-the woman believes in old wives' tales rationale: they believe women who eat strawberries while pregnant have strawberry marks on their infants body
The nurse is caring for a pregnant client who is vegan. Which of the following foods should the nurse suggest the client consume as a substitute for restricted foods?
-tofu -legumes -broccoli rationale:sources are high in protein and iron
A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of t he following comments by the nurse is appropriate at this time?
-your weight gain is exactly what we would expect it to be at this time rationale:expected weight gain for a normal BMI during the first trimester is 3-5 lbs
The nurse is working in an outpatient obstetric office assesses four primigravid clients. Which of the client findings should the nurse highlight for the physician?
-24 weeks w/ fundal height at umbilicus -34 weeks experiencing uterine cramping rationale: fundal height at 24 weeks should be 4 cm above the umbilicus and a baby delivered at 34 weeks would be at a high risk for many complications
Which of following findings in an 8 week gestation client, G2 P1001, should the nurse highlight for the nurse midwife?
-BMI of 17 -rubella tier of 1:8 -Hct of 30% rationale: first woman is underweight and would be encouraged to gain more weight (28-40 lbs) the second woman's rubella tier indicates she is not rubella immune increasing risk of being exposed and the third woman is at a high risk of becoming anemic
The nurse notes each of the following findings in a 10 week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?
-FHR via doppler rationale: this is a sign that irrefutably shows that a fetus is in utero
A woman provides the nurse w/ the following OB history: delivered a son (7 years old) at 28 weeks gestation, a daughter (5 years old) at 39 weeks, had a miscarriage 3 years ago, had a first trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman's gravity and para?
-G5 P1122 rationale:
A pregnant woman informs the nurse that her LNMP was on September 20, 2012. Using Nagele's rule, the nurse calculates the client's estimated date of delivery as:
-June 27, 2013 rationale: LNMP subtract 3 months add 7 days and change the year when necessary
An antenatal client is informing the nurse of her prenatal s/s. Which of the following findings would the nurse determine are presumptive signs of pregnancy?
-amenorrhea -breast tenderness -quickening -frequent urination rationale: these are all subjective (presumptive) signs, objective signs are (possible signs) and signs that are absolute are (positive)
Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following?
-avoid eating greasy foods
A nurse is discussing diet w/ a pregnant woman, which of the following foods should the nurse advise the client to avoid consuming during her pregnancy?
-bologna rationale: must be cooked thoroughly before consuming
A client asks the nurse what was meant when the Dr. told her she had a positive Chadwick's sign. Which of the following info about the finding would be appropriate for the nurse to convey at this time?
-it is a bluish coloration of your cervix and vagina rationale: probable sign of pregnancy, color is due to increase in vascularization of the area in response to the high levels of circulating estrogen in the pregnant woman's system
A 12 week gestation client tells the nurse that she and her husband eat sushi at least once per week. She states "I know that fish is good for me so I make sure we eat it regularly." Which of the following responses by the nurse is appropriate?
-it is recommended that fish be cooked to destroy harmful bacteria
A woman who is seen in the prenatal clinic is found to be 8 weeks pregnant, she confides to the nurse that she is afraid her baby may be permanently damaged because "I had 5 beers the night I had sex." Which of the following responses by the nurse would be appropriate?
-it is unlikely that the baby was affected
A client makes the following statement after finding out that her pregnancy test is positive, "this is not a good time, I am in college and the baby will be due during final exams!" Which of the following responses would be most appropriate at this time?
-it sounds like you're feeling a little overwhelmed right now rationale: this acknowledges the concerns the client is having
A multigravid client is 22 weeks, which symptom should the nurse expect the client to exhibit?
-leg cramping
A woman delivers a fetal demise that has lanugo covering the entire body, nails that are present on the fingers and toes, but eyes that are still fused. Prior to death, the mother stated that she had felt quickening. Based on this info, the nurse knows that the baby was about how many weeks?
-22 weeks rationale: eyes remain fused until 29 weeks
A client enter the prenatal clinic. She states that she believes she is pregnant. Which of the following hormone elevations will indicate a high probability that the client is pregnant?
-chorionic gonadotropin rationale:probable sign of pregnancy, produced by fertilized egg signaling body to keep corpus luteum alive
A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the that she should notify the Dr immediately if she experiences which of the following s/s?
-convulsions -double vision -epigastric pain -persistent vomiting rationale:danger signs for a more serious complication
During a preconception counseling session, the nurse encourages a couple to prepare a birth plan, which of the following is the most important goal for this action?
-develop a preliminary birth plan
A woman states that she frequently awakens w/ painful leg cramps during the night. Which of the following assessments should the nurse make?
-dietary evaluation rationale: caused by consumption of too little calcium or too much phosphorus
The nurse is providing anticipatory guidance to a woman in her 2nd trimester regarding s/s that are w/in normal limits during the latter half of pregnancy. Which of the following comments by the client indicates that the teaching was successful?
-during the 3rd trimester I may experience frequent urination -during the 3rd trimester I may experience heartburn -during the 3rd trimester I may experience nagging backaches
During a prenatal visit, a gravid client is complaining of ptyalism. Which of the following nursing interventions is appropriate?
-encourage the woman to brush her teeth carefully
A 36 week gravid client is complaining of a dyspnea when lying flat, which of the following is likely a clinical reason for this complaint?
-fundal height rationale: as uterus enlarges it causes the diaphragm to become elevated and the lungs become displaced
A woman has completed her first trimester, which of the following fetal structures can the nurse tell the woman are well formed at this time?
-genitals -heart -fingers -kidneys rationale:by first trimester all major organs are formed
A mother is experiencing nausea and vomiting every afternoon. The ingestion of which of the following spices have been shown to be a safe complementary therapy for this complaint?
-ginger rationale:safe antiemtic agent for pregnant woman
A nurse is providing diet counseling to a new prenatal client. Which of the following dairy products should the client be advised to avoid eating during the pregnancy?
-gorgonzola cheese rationale: this is a soft cheese and harbors an organism that causes listeriosis
The nurse is caring for a prenatal client who states she is prone to developing anemia, which of the following foods should the nurse advise the gravida is the best source of iron?
-hamburger
Which change increases the father's interest and involvement in the pregnancy?
-hearing the fetal heartbeat rationale: often causes the baby to become "real"
A father experiencing couvade syndrome is likely to exhibit which of the following symptoms/behaviors?
-heartburn -abdominal pain -bloating
A 20 year old client states that the at home pregnancy test that she took this morning was positive. Which of the following comments by the nurse is appropriate at this time?
-how do you feel about the results rationale: it is essential for the nurse to determine the client's feelings by asking open-ended questions and determining the client's plan
A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the communicable diseases should be administered to the woman during her pregnancy?
-influenza
it is discovered that a pregnant woman practices pica. Which of the following complications is most often associated w/ this behavior?
-iron-deficiency anemia
When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats: 1 piece of fruit/day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make?
-it would be even better if you were to consume more whole fruits and less fruit juice rationale:juices contain added sugar
A mother has just experienced quickening. Which of the following developmental changes would the nurse expect to occur at the same time?
-lanugo covers the body rationale: this happens at week 20
A nurse is working in the prenatal clinic. Which of the following findings seen in third trimester pregnant woman would the nurse consider to be w/in normal limits?
-leg cramps -varicose veins -hemorrhoids -lordosis
A Chinese immigrant is being seen in the prenatal clinic. When providing nutrition counseling, which of the following factors should the nurse keep in mind?
-many Chinese believe pregnant women should eat cold foods rationale: many cultures believe pregnancy to be a "hot" period therefore they need to consume "cold" foods and drinks to balance out the equilibrium
The nurse plans to provide anticipatory guidance to a 10-week gravid client who is being seen in the prenatal clinic. Which of the following info should be a priority for the nurse to provide?
-methods to relieve back pain rationale: she will soon be entering the 2nd trimester where she is likely to experience backaches
The nurse takes a history of a client, G2 P1001, at her first prenatal visit. Which of the following statements would indicate that the client should be referred to a genetic counselor?
-my first child has cystic fibrosis rationale: cystic fibrosis is an autosomal recessive disorder and a client w/ a genetic history should be referred
A nurse has identified the following nursing diagnosis for a prenatal client: altered nutrition: less than body requirements r/t poor folic acid intake. Which of the following foods should the nurse suggest the client consume?
-oranges and spinach
A gravida, G1 P0000, is having her first prenatal physical exam. Which of the following assessments should the nurse inform the client that she will be having that day?
-pap smear -CBC rationale: client's undergo complete OB/physical assessments to provide a baseline
Which exercise would be taught to a pregnant woman who complains of a backache?
-pelvic tilting rationale: reduces backpain
Which of the following skin changes should the nurse highlight for a pregnant women's health care practicioner?
-petechia rationale: these are seen in hemorrhagic conditions
Which of the following vital sign changes should the nurse highlight for a pregnant woman's obstetrician?
-prepregnancy BP 100/60 -- third trimester BP 140/90
A client state that she is a strong believer in vitamin supplements to maintain her health. The nurse advises the woman that it is recommended to refrain from consuming excess quantities of what vitamin?
-vitamin D rationale: teratogenic in large quantities
A client enters t he prenatal clinic. She states that she missed her period yesterday and used a home pregnancy test this morning. She states the results were negative but still thinks she is pregnant. Which of the following statements would be appropriate for the nurse to make at this time?
-we could do a blood test to check rationale: they measure the exact quantity of Hcg in the blood stream and are more accurate than urine tests
A 16-year-old, G1 P0000, is being seen at her 10 week gestation visit. She tells the nurse that she felt the baby move that morning, which of the following responses by the nurse is appropriate?
-would you please describe what you felt for me rationale: quickening doesn't occur until week 16-20, the nurse would need to elicit more info from the teen to determine what she felt