Set 2
A client is in her first trimester of pregnancy. She complains of nausea, increased fatigue, increased urination, and emotional lability. What is the best nursing action?
Discuss with the client that these are normal discomforts of the first trimester.
A woman (gravida 3, para 2) is in labor. She initially started the labor process requesting that pain medications not be administered. She wanted a "natural" birth process. The client is completely effaced and dilated to 7 cm and is crying and asking for something for pain. The nurse has an order for 50 mg of Demerol, IM, if the client requests pain medication. What is the best nursing response?
Do not give the medication; the woman is too close to delivery, and the medication would sedate the infant.
A pregnant client at 12 weeks of gestation complains of feeling nauseated all day long. The nurse would advise her to:
Eat small but frequent meals
The nurse encourages a client in labor to assume a side-lying position. What is the purpose of this position?
Enhances venous return
A woman is taking oral combination estrogen/progestin birth control pills. What will be important for the nurse to explain to the client regarding complications?
Report any leg tenderness, headaches, or changes in vision.
A client is experiencing a severe episode of preeclampsia. She is being treated with magnesium sulfate. The client demonstrates the following assessment findings: no seizure activity, blood pressure decreased from 170/90 to 140/80 mm Hg, and urine output increased to 40 mL/hr. What is the nurse's interpretation of this information?
The medication is having the desired therapeutic action.
Ten weeks into a client's pregnancy, she begins to experience a small amount of vaginal bleeding. The client's human chorionic gonadotropin (HCG) levels remain elevated. The nurse would instruct the client to notify the doctor if which of the following occurred?
Abdominal pain or cramping
A client is receiving magnesium sulfate intravenously for severe preeclampsia. What is an important nursing action while the client is receiving this medication?
Check the patellar reflexes every hour.
During the first stage of labor, the cervix becomes thin and indistinct from the body of the uterus. What is the term the nurse would use to describe this observation?
Effacement
The nurse is monitoring a client in labor who is receiving oxytocin (Pitocin). What is a priority nursing intervention for clients who are receiving this medication?
Every 10 to 15 minutes evaluate the frequency and duration of the contractions.
What would be important to include in the discharge teaching of a pregnant woman who is being discharged from the hospital after placement of cerclage?
Explain that the presence of any uterine cramping or low backache may indicate preterm labor and should be reported.
A client is admitted with preeclampsia and is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 100,000, an elevated aspartate transaminase (AST) level, and a hematocrit of 22%. The nurse understands that these findings are indicative of:
HELLP syndrome
The pelvic examination reveals the fetus to be at -1 station. What information does this give the nurse about the presenting part of the fetus?
Is above the ischial spines
When instructing a pregnant client concerning the need for rest, the nurse encourages lying in a position that would improve placental circulation. The nurse would know her teaching was effective if the client assumed which position?
Left lateral Sims'
A client is receiving magnesium sulfate to help suppress preterm labor. The nurse should watch for which sign of magnesium toxicity?
Loss of deep tendon reflexes
The nurse understands that the unique advantage of a ParaGard T380A copper intrauterine device (IUD) is that it:
May be left in place for up to 10 years
The nurse is encouraging the pregnant woman to eat a diet rich in folic acid. Which of the following food sources would provide the most folic acid?
Meat and dark green, leafy vegetables
When teaching a client about side effects of birth control, the most common side effect associated with depomedroxyprogesterone (DMPA) (Depo-Provera) is:
Menstrual cycle changes
The nurse is assisting with an aminoinfusion. What is an important nursing intervention during this procedure?
Monitor the intensity and frequency of uterine contractions during the procedure.
A young woman calls the clinic and reports missing her period. She states that she used a home pregnancy test last night and the results were negative. She tells the nurse that her breasts are tender and that she feels nauseated most of the day. What does the nurse understand about home pregnancy tests?
Negative results should be followed up in the presence of pregnancy symptoms.
A woman states that her last menstrual period was January 11. Using Nägele's rule, what would be her expected date of birth (EDB)?
October 18
A 38-year-old female client is seen for her 6-week postpartum exam by the nurse practitioner. The client was breastfeeding for a short time but discontinued 4 weeks ago. Her menses have resumed. She is contemplating another pregnancy in a year or so, but if she became pregnant before that, she would not mind. She is seeking contraception. She smokes one pack per day. The exam findings are normal, with the uterus being well involuted. The nurse understands that which of the following birth control methods would be contraindicated for this client?
Oral contraceptive agents
The nurse schedules a 38-year-old primigravida client for an amniocentesis at 16 weeks' gestation. What would the nurse explain that the purpose of this procedure is?
Perform genetic studies.
A multigravida client comes into the ER complaining of abdominal pain. She is at 30 weeks' gestation. On assessment, the nurse observes complete dilation and effacement of the cervix with the perineal area bulging and the infant's head crowning. The mother states she is feeling a strong urge to push. What is the best nursing action?
Place even gentle pressure on infant's head and support it through the birth canal.
What is the appropriate nursing action when preparing a client for transvaginal ultrasonography?
Place her in lithotomy position.
The nurse is checking a laboring client. Her assessment reveals the head at +3 station. What will the nurse do?
Prepare for the delivery of the infant.
A client is at 30 weeks of gestation when she comes in for her regular prenatal checkup. What nursing assessment findings would cause the most concern?
Presence of 2 g of protein in a 24-hour urine collection, elevated blood pressure
A young primigravida client is diagnosed with preeclampsia. The nurse would assess the client for indications of progression of the condition and/or complications. What assessment finding would be most critical?
Seizure activity
A client is diagnosed with a ruptured tubal or ectopic pregnancy. What would the nurse expect to find on the assessment of this client?
Sharp, stabbing pain localizing to left lower quadrant with blood pressure (BP) of 90/58 mm Hg
The nurse is assessing a woman who has just started receiving a continuous epidural anesthetic for a normal term delivery. What is important for the nurse to monitor regarding the effects of epidural anesthesia?
Significant decrease in blood pressure
The nurse walks into the room of a woman who has a diagnosis of preeclampsia and finds the woman having a seizure. What is a priority nursing action?
Stay with the woman and call for assistance.
The nurse understands that combination oral contraceptive pills prevent pregnancy primarily by:
Suppressing ovulation
A woman calls the clinic and tells the nurse that she forgot to take her birth control pill yesterday evening. What would be an appropriate nursing intervention?
Tell the woman to take the missed pill as soon as she remembers and take her next dose as scheduled.
The nurse is caring for a client who is not pregnant but who is considering pregnancy. A rubella titer has been done, and the titer was negative. What will be important for the nurse to tell this client?
The client should get a rubella vaccine now and not get pregnant for at least a month.
A 26-year-old female client comes into the ER complaining of lower left side abdominal pain. It began suddenly and has gotten worse over the past few hours. What is the most important information for the nurse to obtain?
The date of her last menstrual period and whether she could be pregnant
A pregnant client is Rh negative. The nurse is preparing a teaching plan. What will be important to include in teaching this client about Rho(D) immune globulin (RhoGAM)?
The medication will be administered before and within 72 hours after the birth of an Rh-positive infant.
A pregnant client with diabetes is in the clinic for a prenatal visit. She is at 34 weeks of gestation. She was last seen in the clinic 1 month ago, and her dose of insulin had not changed from the previous month. This month her blood sugar remains in control with the same amount of insulin. The nurse would interpret this information in which of the following ways?
The mother may be developing problems with placental insufficiency and should be thoroughly evaluated.
During a nonstress test (NST), the nurse notes three fetal heart rate (FHR) increases of 20 beats/min, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest?
The test result is reactive at this time.
What finding would the nurse consider normal that happens to the musculoskeletal system as it adapts to the changes that occur during pregnancy?
The woman will have increased lordosis.
The nurse is assessing a client who is at 36 weeks' gestation; this client has type 2 diabetes. The client says she is extremely upset by the fact that she will not be able to breastfeed her infant. The best nursing response would be based on what information?
There are no contraindications to diabetic mothers' breastfeeding their infants; it will be important for the mother to carefully monitor her blood glucose levels and insulin needs.
A primigravida client is experiencing Braxton-Hicks contractions. Which statement is true concerning these contractions?
They do not increase in intensity or frequency.
A woman who recently found out that she was pregnant has started to have bleeding and cramping. When the health care provider exams her, he notes that the cervix is closed. A diagnosis of which type of abortion would be made?
Threatened
Which of the following circumstances is most likely to cause uterine atony leading to postpartum hemorrhage?
Urine retention
A woman who is 36 weeks pregnant is brought to the ER by her husband. She has been experiencing painless vaginal bleeding for about an hour. What would be the priority nursing actions?
Place the client supine, begin oxygen administration, and start an IV line.
A multigravida client is diagnosed with preeclampsia and HELLP syndrome. The nurse's top priority is to assess the client's:
Platelet count
Which statement about the results of a contraction stress test (oxytocin challenge test) is considered accurate?
Positive if late decelerations occur in more than half of the contractions
The nurse is caring for a 20-year-old primigravida client who has been in the first stage of labor for about 8 hours. What assessment findings would indicate the client is progressing into the second stage of labor?
Cervical effacement at 100%, dilatation of 10 cm
Which finding would be considered normal for a woman in her second trimester?
Change in pulse rate from 70 to 82 rate
After rupture of the amniotic fluid membranes, what is the nurse's immediate action?
Check fetal heart rate.
A positive pregnancy test result is related to the presence of which hormone?
Chorionic gonadotropin
A client is in the twelfth week of pregnancy. The nurse understands that the following procedure may be performed to detect genetic disease:
Chorionic villi sampling
The nurse is assessing a client who has been diagnosed with severe preeclampsia. Which assessment information would require the nurse to notify the physician immediately?
Headache, severe epigastric pain, hyperreflexia
Which of the following signs should the nurse expect to find during physical assessment of a primigravida client in her eighth week of gestation?
Hegar's sign
At the beginning of her third trimester, a client reports she is having some discomfort in her lower back. What would the nurse check?
Her posture and the type of shoes she usually wears
A woman who has severe acne is taking tetracyclines. She asks the nurse about the pill as a contraceptive choice. What would be an appropriate nursing response?
"Antibiotics such as tetracyclines will reduce the effectiveness of the pill."
A client reports that her last menstrual period was November 10. She asks the nurse, "When will my baby be due?" What is the best answer?
"Around the third week of August"
Which of the following statements by the client reflects successful teaching during a natural family planning session?
"I will be most likely to get pregnant within 14 days before my period."
To determine the ovulatory period, the client is to take her basal body temperature daily. The nurse would determine that the client understands how to take her basal body temperature when she says:
"I'll take my temperature upon awakening each day."
A woman is beginning oral combination contraceptives. She asks the nurse what she should do if she misses a pill. What would be the best nursing response?
"Take the missed pill with the next regular scheduled pill as soon as she is aware of it."
A woman is experiencing infertility and has decided to take the prescribed medication clomiphene citrate (Clomid) to treat the infertility. While discussing the effects of the medication, the woman expresses concern that she may have a multiple birth. What would be an appropriate nursing response?
"The risk of multiple births can occur; let us discuss this further."
12. An examination reveals that a client is 8 weeks pregnant and is in apparent good health. What would be routine prenatal laboratory studies? Select all that apply.
1,2,3,4,6
The nurse is preparing a teaching plan for a client who has just had her pregnancy confirmed. What will be important for the nurse to include in the teaching plan? Select all that apply.
1,3,6
At a prenatal clinic, a nurse is assessing a woman who is in the third trimester of her pregnancy. What nursing observation would cause the most concern?
2+ protein on urine dipstick
The woman will have increased lordosis.
2,3,4,5,6
Which of the following dietary instructions would be appropriate for the client after identification of pregnancy in her first term? Select all that apply.
2,3,5
To maintain consistency in evaluating the blood pressure on pregnant clients, the nurse needs to be aware of which techniques? Select all that apply.
2,4,5,6
The nurse is assessing a woman who is 10 weeks pregnant. Her obstetric history includes a previous spontaneous abortion at 14 weeks of gestation, a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system?
3-1-0-1-0
Which of the following statements describes the correct use of a condom? Select all that apply.
4,5
A client is admitted to the hospital after experiencing a miscarriage at 16 weeks of gestation. The nurse enters her room to find her crying. What would be appropriate for the nurse to do at this time?
Acknowledge that losing a pregnancy is a very difficult time and sit with her for a while.
The nurse is assessing a primigravida client who is at 26 weeks' gestation; the client's blood type is AB negative, her serology is negative, and she has a history of one miscarriage at 20 weeks. Based on this information, what will the nurse anticipate being ordered for this client?
Administration of Rho(D) (RhIG or RhoGAM) at 28 weeks' gestation
The nurse understands that prenatal testing for human immunodeficiency virus (HIV) is recommended for which women?
All women, regardless of risk factors
Which of the following statements would the nurse know about hemorrhagic complications that may present during pregnancy?
An incompetent cervix usually leads to a spontaneous abortion.
When preparing a client for an amniocentesis procedure, the nurse should:
Ask the client to void first
A client is 37 weeks' pregnant and is admitted to the hospital with bright red vaginal bleeding, complaining of abdominal discomfort, but no contractions. After assessing the client's vital signs and determining the fetal heart rate, which is 105, what is the most important information to obtain?
At what time the client last ate.
A client is in the prenatal clinic. She asks the nurse how she can be sure that she is pregnant. The nurse's answer would be based on what information?
Auscultation of the fetal heart rate by Doppler ultrasonography
The nurse is caring for a client in labor. How are contractions timed?
Beginning of one to the beginning of the next
A primigravida client at 26 weeks' gestation has been administered a glucose tolerance test. What would the nurse anticipate as a normal finding?
Blood glucose level of 110 mg/L at 3 hours
Which observation by the nurse would cause the most concern regarding a pregnant client at 25 weeks of gestation that might be developing preeclampsia?
Blood pressure 146/92 mm Hg
The nurse is conducting prenatal teaching with a 16-year-old primigravida client during her first prenatal visit. What is the most important information for the nurse to discuss with the client on the first prenatal visit?
Components of a balanced diet, with increased intake of meat and poultry, and increased intake of whole-grain products
A client was past term for her pregnancy and was admitted to the hospital for an induction. An IV was established and oxytocin (Pitocin) has been infusing for about 3 hours. The contractions have been about 45 to 60 seconds in duration and about 2 to 3 minutes apart; cervical dilatation is 6 cm. Blood pressure is 130/80 mm Hg, pulse is 90 beats/min, and respirations are 28 breaths/min; the fetal heart rate is between 140 and 170 beats/min. What observation would cause the nurse the most concern?
Contractions averaging 60 seconds in duration every 2 minutes
During a prenatal visit, the client tells the nurse that she does not drink milk. What would be an appropriate food choice that would be high in calcium?
Cooked dried beans
The labor monitor tracing shows variable decelerations. What complication would the nurse anticipate is occurring?
Cord compression
A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours and is complaining of thirst and warmth. Assessment findings are as follows: pulse rate of 90 beats/min, respiratory rate of 10 breaths/min, blood pressure of 150/90 mm Hg, absent deep tendon reflexes. What is a priority nursing measure?
Discontinue the magnesium sulfate infusion and switch to main IV.
The nurse is monitoring a woman with severe preeclampsia who has been receiving magnesium sulfate by intravenous infusion for the past 6 hours. Assessment findings on the woman are as follows: pulse rate of 86 beats/min, respiratory rate of 18 breaths/min, blood pressure of 165/112 mm Hg, 2+ deep tendon reflexes. What medication would the nurse anticipate the physician ordering?
Hydralazine (Apresoline)
A woman is taking oral combination contraceptives (OC). What would be important for the nurse to teach the client regarding the medication?
If you have to take an antibiotic, ask the health care provide if it has any effect on the oral contraceptives.
A pregnant client at 16 weeks' gestation has a blood sample for rubella antibody screening drawn. The test results reveal a low titer. When discussing the results with the client, what is an appropriate nursing action?
Instruct the client to receive the rubella immunization immediately after delivery.
An 18-year-old is being given medroxyprogesterone (Depo-Provera) for contraception at the college health clinic. What initial teaching must be included before administration?
Irregular menses and weight gain may occur.
A woman who has missed her period for 5 weeks states that she has been having nausea with some vomiting in the morning hours. The woman also states that she may have a urinary tract infection because of frequent urination and fatigue. The nurse would recognize these symptoms to be:
Presumptive signs of pregnancy
A client has a positive pregnancy test. On examination it is determined that Chadwick and Hegar signs are present. How would these signs be classified regarding signs of pregnancy?
Probable signs
The nurse is teaching a prenatal class. What would be most important for the nurse to teach the women to do if their membranes rupture before admission to the hospital?
Refrain from sexual intercourse.
What will be important for the nurse to assess in the client immediately after an amniocentesis?
Spontaneous rupture of the membranes
A lecithin-sphingomyelin (L/S) ratio is ordered for a primigravida client at 35 weeks of gestation. What is the goal of this test?
To determine fetal lung maturity
A woman in her second trimester of pregnancy is coming in for evaluation and monitoring the growth of her twins. Which test would be appropriate for the nurse to explain to the client?
Ultrasound
The nurse is caring for a client who is at the beginning of her third trimester of pregnancy. The client has been admitted in preterm labor, and magnesium sulfate is being used. Contractions are occurring about every 4 to 5 minutes and lasting 1 to 1½ minute; blood pressure is 130/88 mm Hg; respirations are 22 breaths/min; pulse is 98 beats/min. What nursing observation would cause the nurse the most concern?
Urinary output of a total of 240 mL for the past 8 hours
The nurse is assessing a client 12 hours after a prolonged labor and delivery. What assessment data would cause the nurse the most concern?
Uterine fundus palpated to the right of the umbilicus
The nurse is teaching a new prenatal client, who is 12 weeks of gestation to call the clinic and report which symptom immediately to her health care provider?
Vaginal bleeding
A single woman is discussing contraception with the nurse and expresses a preference for a diaphragm. Which factor in her history would make a diaphragm a poor choice?
Three urinary tract infections (UTIs) in the past year
The nurse is monitoring a client during labor and observes an erratic fetal heart pattern on the monitor at the height of the contraction. What is the first action of the nurse?
Check the monitor leads for placement.
A woman pregnant with a single fetus has a preconception body mass index (BMI) of 20. During her first prenatal visit at 12 weeks of gestation, she had gained 2 kg (4.4 lb) since conception. How would the nurse interpret this data?
Weight gain is considered normal.
Which statement would the nurse make to the client about striae gravidarum?
Will fade from their present pinkish-reddish appearance
