Ante/Intra Partum NCLEX

A nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breast-feed the infant after delivery. Which response by the nurse is appropriate?

*1. "Breast-feeding is contraindicated."* 2. "Breast-feeding is allowed as long as the mother is taking zidovudine (AZT)." 3. "Breast-feeding is allowed as long as the infant is not showing signs of human immunodeficiency virus (HIV) infection." 4. "Breast-feeding is allowed as long as the infant receives an immunization for HIV." *Rationale:* The woman with AIDS will need to know that breast-feeding is contraindicated but that she can provide all other care for her infant. Characteristically, the newborn is asymptomatic at birth, and signs and symptoms usually become obvious during the first year of life. No immunization is available for HIV.

A nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which statement accurately describes the normal cardiovascular symptom experienced during pregnancy?

*1. Increase in pulse* 2. Decrease in cardiac output 3. Increase in blood pressure 4. Decrease in blood volume *Rationale:* Between 14 and 20 weeks, the pulse increases slowly, up 10 to 15 beats from normal, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy, returning to baseline in the second half.

The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? *Select all that apply.*

*1. Proteinuria* *2. Hypertension* 3. Low-grade fever *4. Generalized edema* 5. Increased pulse rate 6. Increased respiratory rate *Rationale:* The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia.

A nurse is gathering data from a pregnant client about physiological risk factors. The nurse would be sure to obtain which priority data?

1. Life stress 2. Self-care needs 3. Support systems *4. Weight and height* *Rationale:* Height and weight are important factors to assess when determining physiological risk factors. Although options 1, 2, and 3 are important to determine, they are not directly related to physiological risk factors.

A nurse in the labor room is caring for a client in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

1. Notify the registered nurse. 2. Administer oxygen via face mask. 3. Place the mother in Trendelenburg's position. *4. Document the findings and continue to monitor the fetal patterns.* *Rationale:* Early deceleration of the FHR is a gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Options 1, 2, and 3 are unnecessary.

A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:

1. Placing the external fetal monitor over the fetus that is most anterior to the mother's abdomen 2. Placing the external fetal monitor over the fetus that is most posterior to the mother's abdomen *3. Placing external fetal monitors so that each fetal heart rate is monitored separately* 4. Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus *Rationale:* In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 1, 2, and 4 are incorrect because these actions would not provide information regarding the status of each fetus.

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which of the following statements by the client would identify the need for further teaching regarding the hemorrhoids?

*1. "Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born."* 2. "Hemorrhoids are aggravated by standing for long periods. I need to lie down periodically during the day to relieve the pressure." 3. "Hemorrhoids can be gently pushed back inside my body using a lubricant." 4. "Diet is very important in the treatment of hemorrhoids. Plenty of liquids and a balance of bulk in the diet are needed." *Rationale:* Hemorrhoids are varicosities and are most likely to be precipitated during pregnancy by the pressure of the growing fetus inside the abdominal cavity. Standing aggravates the problem. Dietary factors such as fluids and roughage, and the technique of manual reduction should be included in the plan of care. Hormonal changes are not a factor.

A nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement by the client indicates an immediate need for further investigation?

*1. "I don't like my face anymore. I always look like I have been crying."* 2. "I don't like my breasts anymore. These silver lines are ugly." 3. "I don't like my stomach anymore. That brown line is disgusting." 4. "I don't like my figure anymore. My clothes are all too tight." *Rationale:* Options 2, 3, and 4 are dealing with body image. Although these comments should not be ignored, the need for follow-up is not urgent. Option 1 is an implication of periorbital and facial edema, which could be indicative of gestational hypertension (GH). Because this is an adolescent who has not sought early prenatal care, she is at higher risk for the development of GH.

A nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

*1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."* 2. "I should drink 8 to 12 glasses of liquid a day, and I can count the tea, fruit juices, or milk that I drink." 3. "I should drink 8 to 12 glasses of liquid a day, and I can count the carbonated soft drinks that I consume." 4. "I should drink 8 to 12 glasses of liquid a day, and I can count the coffee that I drink." *Rationale:* The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation: 8 to 12 glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.

A nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for more teaching regarding possible complications of preeclampsia?

*1. "I should expect that my urine output will decrease."* 2. "Blurred vision is not a normal occurrence." 3. "I will be alert to any change in fetal movements." 4. "I need to be concerned if I develop constipation." *Rationale:* Warning signs and symptoms of preeclampsia to be reported include decreased urinary output, headaches and blurred vision, abdominal pain, and a change in fetal movement, particularly a decrease. Constipation is not associated with preeclampsia.

The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term?

*1. "It is the fetal movement that is felt by the mother."* 2. "It is the compressibility of the lower uterine segment." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." *Rationale:* Quickening is fetal movement that appears usually at week 16 to 20, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. A compressibility of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; this is known as uterine souffle. This sound is the result of blood circulation to the placenta, and it corresponds with the maternal pulse.

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process?

*1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."* 2. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." 3. "The low levels of estrogen and progesterone increase the release of follicle-stimulating hormone and luteinizing hormone." 4. "The high levels of estrogen and progesterone promote the release of follicle-stimulating hormone and luteinizing hormone." *Rationale:* Because the placenta is implanted low Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, thus inhibiting the release of follicle-stimulating hormone and luteinizing hormone, which are necessary for ovulation. Options 2, 3, and 4 are incorrect.

A 32-week gestational client 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?

*1. "Tell me about your concerns."* 2. "Your husband called to say he's coming to be with you." 3. "Many women have this problem with no further complications." 4. "You have an excellent health care provider; if anyone can save your baby, he can." *Rationale:* The client is apprehensive and the nurse needs to assist the client in exploring her feelings and concerns. The remaining options do not focus on the client's feelings. Additionally, there are no data to suggest the client is married.

A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?

*1. "Tell me what concerns you have."* 2. "Don't worry. Everything will be fine." 3. "Why don't you want to have this test done?" 4. "The health care provider has scheduled this test for a reason." *Rationale:* The nurse needs to gather more data and assist the client in exploring her feelings about the test. Options 2, 3, and 4 are blocks to communication and are nontherapeutic nursing responses.

A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure?

*1. "The uterus weighs about 2 ounces."* 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round and weighs approximately 1000 grams." *Rationale:* Before conception, the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 ounces) and has a capacity of about 10 mL (0.3 ounce). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 pounds) and has a sufficient capacity for the fetus, placenta, and amniotic fluid.

A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which of the following responses, if made by the student, indicates an understanding of the anatomy of this structure?

*1. "The uterus weighs about 2 ounces."* 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round in shape and weighs approximately 1000 grams." *Rationale:* Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz), and it has a capacity of about 10 mL (1/3 oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb), and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

*1. "There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."* 2. "There is no risk to the newborn of an HIV-infected mother during delivery." 3. "Newborns who contract HIV during delivery will show immediate symptoms." 4. "A newborn cannot contract HIV during delivery." *Rationale:* There is a risk of transmission of HIV to a newborn at the time of delivery if the pregnant woman is HIV positive. Newborns may not exhibit symptoms for 18 months or more. Therefore the remaining options are incorrect.

A woman at 20 weeks of gestation calls the health care provider's office and speaks to a nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which of the following is the least helpful response to the client?

*1. "This is an emergency; you should come to the clinic within the hour."* 2. "Drink three glasses of water and lie on your left side for 1 hour." 3. "Palpate for contractions and if four or more are felt within 1 hour, you need to be seen by the health care provider." 4. "Tell me about your activity, food, fluid, and medication intake for the past 24 hours." *Rationale:* The woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation. Option 4 addresses the process of data collection and is an important initial component of care.

A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which of the following statements by the nurse indicates an understanding of the problem?

*1. "You feel you are having difficulty fulfilling your role as a wife."* 2. "You are afraid your husband will go to dinner without you." 3. "You are not physically able to go to dinner and should stay at home." 4. "You should go to dinner. Others will understand if you don't feel well." *Rationale:* There are no data to support the fear that the wife will be left at home. Options 3 and 4 are examples of giving advice and do not lead to open communication with the pregnant woman. Option 1 reflects a feeling that the woman may be having. By identifying this feeling, the nurse provides the opportunity for further discussion.

A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is:

*1. 1 cm above the ischial spines* 2. 1 fingerbreadth below the symphysis pubis 3. 1 inch below the coccyx 4. 1 inch below the iliac crest *Rationale:* Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is isolated:

*1. 1 cm above the ischial spines* 2. 1 fingerbreadth below the symphysis pubis 3. 1 inch below the coccyx 4. 1 inch below the iliac crest *Rationale:* Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and noted as a negative number above the line and a positive number below the line. Options 2, 3, and 4 are incorrect.

A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which should the nurse anticipate to be prescribed for the mother?

*1. A 3-hour glucose tolerance test* 2. A sliding-scale regular insulin dose 3. Administration of an oral hypoglycemic agent 4. Administration of NPH insulin on a daily basis *Rationale:* A maternal glucose is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes. Options 2, 3, and 4 would not be prescribed based solely on the maternal glucose levels. Further followup would be implemented.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated?

*1. A change in the uterine contour* 2. Sudden and sharp abdominal pain 3. A shortening of the umbilical cord 4. A decrease in blood loss from the introits *Rationale:* Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness but not sudden and sharp abdominal pain.

A nurse is collecting data from a prenatal client. The nurse determines that which of the following places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

*1. A history of intravenous (IV) drug use in the past year* 2. Living in an area where HIV infections are minimal 3. A history of one sexual partner within the past 10 years 4. A spouse who is heterosexual and has had only one sexual partner in the past 10 years *Rationale:* HIV is transmitted by intimate sexual contact and by the exchange of body fluids, exposure to infected blood, and the transmission from an infected woman to her fetus. Women who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases or a history of multiple sexual partners and those who use or have used IV drugs. Options 2, 3, and 4 are not situations that contribute to contracting HIV infection.

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. The nurse interprets these findings as indicating:

*1. A negative test* 2. A positive test 3. A suspicious test 4. An unsatisfactory test *Rationale:* A reactive nonstress test (normal/negative) indicates a healthy fetus. A nonreactive nonstress test is an abnormal test and requires further followup. A suspicious test result also requires further followup. An unsatisfactory test cannot be interpreted because of the poor quality of the fetal heart rate findings.

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign, and the nurse determines that this sign is indicative of:

*1. A softening of the cervix* 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus *Rationale:* In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening will be noted during pelvic examination by the examiner. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta. Human chorionic gonadotropin is noted in maternal urine in a urine pregnancy test. Goodell's sign does not indicate the presence of fetal movement.

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:

*1. A softening of the cervix* 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus *Rationale:* During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin is noted in maternal urine with a positive urine pregnancy test. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; it is the result of blood circulating through the placenta.

A client diagnosed with severe preeclampsia is on magnesium sulfate by continuous intravenous infusion. Which finding suggests to the nurse that the next dose of this medication should be held?

*1. Absence of deep tendon reflexes* 2. Urinary output of 45 mL in the past hour 3. Respiratory rate of 20 breaths per minute 4. Decrease in blood pressure from 180/100 to 150/90 mm Hg *Rationale:* Adverse side effects with magnesium sulfate include central nervous system depression. The nurse monitors the client to ensure that the respiratory rate is greater than 13 breaths per minute, that the urine output is greater than 30 mL/hour, and that deep tendon reflexes are present. A decrease in blood pressure is a positive finding. The absence of deep tendon reflexes indicates the need to discontinue the infusion of this medication.

A nurse is monitoring a client who is in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, the nurse immediately:

*1. Administers oxygen via face mask to the mother* 2. Documents the findings 3. Transports the client to the delivery room 4. Increases the rate of an oxytocin (Pitocin) infusion *Rationale:* Late decelerations are caused by uteroplacental insufficiency that occurs as a result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the immediate action in this situation.

A nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor:

*1. All vital signs, especially heart rate and blood pressure* 2. Frequency, duration, and intensity of contractions 3. The presence of both clear and red vaginal discharge 4. Effacement and dilation of the cervix *Rationale:* In abruptio placentae, the placenta has become detached. It could be marginal where bleeding is noted or concealed where there is no evidence of bleeding. The client will manifest signs of shock if bleeding occurs, and this complication will be noted by a change in vital signs. Although options 2, 3, and 4 identify items that will be monitored in the client in labor, these are not specifically associated with the subject of the question.

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? *Select all that apply.*

*1. Allows for fetal movement* *2. Is a measure of kidney function* *3. Surrounds, cushions, and protects the fetus* *4. Maintains the body temperature of the fetus* 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus *Rationale:* The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, it maintains the body temperature of the fetus, and it helps to measure kidney function, because the amount of fluid is based on the amount of urination from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus, and it provides an exchange of nutrients and waste products between the mother and the fetus.

A nursing instructor asks a student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? *Select all that apply.*

*1. Allows for fetal movement* *2. Is a measure of kidney function* *3. Surrounds, cushions, and protects the fetus* *4. Maintains the body temperature of the fetus* 5. Prevents large particles, such as bacteria, from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus *Rationale:* The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, maintains the body temperature of the fetus, and helps assess kidney because it contains urine from the fetus. The placenta prevents large particles, such as bacteria, from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's statement, the nurse understands that the client is experiencing which of the following problem?

*1. Anxiety and fear* 2. Feeling powerless 3. Lacking parenting skills 4. Lacking sensory perception *Rationale:* The client is expressing anxiety and fear related to the situation. Powerlessness would be identified if the client verbalized a lack of control over the situation. Lacking parenting skills is unrelated to the situation. Lacking sensory perception may be displayed by confusion.

A nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which of the following problems would the nurse expect to note on the plan of care?

*1. Anxiety related to a slow progress of labor* 2. Anxiety related to previous parenting issues 3. Anxiety related to the inability to achieve relaxation 4. Anxiety related to physical and emotional maternal exhaustion *Rationale:* An experience can be influenced by past experiences, culture, support from family or significant other, or by preparation. Dystocia can cause a slow progress of the labor. Maternal anxiety is compounded by the crisis of the slow labor. Options 2, 3, and 4 are unrelated to dystocia.

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Part of the plan of care for this client should be to monitor for:

*1. Any bleeding, such as in the gums, petechiae, and purpura* 2. Enlargement of the breasts 3. Periods of fetal movement followed by quiet periods 4. Complaints of feeling hot when the room is cool *Rationale:* Bleeding is an early sign of disseminated intravascular coagulation (DIC), a complication of preeclampsia, and should be reported. Options 2, 3, and 4 are normal occurrences in the last trimester of pregnancy.

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which of the following treatments would the nurse consider to be safe for this maternity client?

*1. Laser therapy* 2. Use of cytotoxic agents 3. Treatment with interferon 4. All treatment should be avoided. *Rationale:* Laser therapy is the most effective method of treatment for this disorder that is considered safe for pregnancy. Medications for the disease are considered toxic to the fetus. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis. The exact route of perinatal transmission is unknown.

A 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:

*1. Avoid further stress on the maternal immune system.* 2. Reduce the risks of anemia during pregnancy. 3. Minimize the possibility of preterm labor. 4. Minimize the risk of premature rupture of membranes. *Rationale:* The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 1 identifies the primary nursing management subject for the HIV-infected client.

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign(s) of pregnancy that the nurse should recognize? *Select all that apply.*

*1. Ballottement* *2. Chadwick's sign* *3.Uterine enlargement* *4. Braxton Hicks contractions* 5. Outline of fetus via radiography or ultrasound 6. Fetal heart rate detected by a non electronic device *Rationale:* The probable signs of pregnancy include uterine enlargement, Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy), Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (the rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?

*1. Baseline fetal heart rate* 2. Intensity of contractions 3. Maternal blood pressure 4. Frequency of contractions *Rationale:* The nurse should first determine the baseline fetal heart rate. Although options 2, 3, and 4 are components of the data collection process, the fetal heart rate is the priority.

A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?

*1. Betamethasone* 2. Nalbuphine (Nubain) 3. Misoprostol (Cytotec) 4. Rho(D) immune globulin (RhoGAM) *Rationale:* Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. Nalbuphine (Nubain) is an opioid analgesic. Misoprostol (Cytotec) is a prostaglandin that is given to ripen and soften the cervix and to stimulate uterine contractions. Rho(D) immune globulin (RhoGAM) is given to RH-negative clients to prevent sensitization.

Which of the following histories would place a maternity client at risk for uterine rupture?

*1. Cesarean section birth* 2. Abruptio placentae 3. Placenta previa 4. Preterm labor *Rationale:* A client with a history of a previous cesarean birth is at most risk for uterine rupture. When a client has a cesarean delivery, an incision is made in the uterine wall. The site of the incision can produce a weakened area in the uterine wall. The conditions identified in options 2, 3, and 4 do not place the client at risk for uterine rupture.

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?

*1. Change in uterine shape* 2. Sudden abdominal pain 3. Shortened umbilical cord 4. Decreased blood flow from the introits *Rationale:* As the placenta separates, the uterus changes from a discoid to a globular shape. Other signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, and a firmly contracted uterus. The client may experience vaginal fullness but not sudden abdominal pain.

A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client?

*1. Client exhibits no signs of fetal distress.* 2. Client expresses an understanding of her condition. 3. Client identifies and uses available support systems. 4. Client demonstrates compliance with activity limitations. *Rationale:* Option 1 clearly identifies a physiological need. Options 2, 3, and 4 may be a component of the plan of care, but the physiological integrity and safety of the mother newborn dyad are the priorities.

A client age 23 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?

*1. Concern about her appearance* 2. Anxiety about the pregnancy 3. Need to isolate self from others 4. Inability to carry out expected roles *Rationale:* Although the nurse might consider all of these problems initially, the information described in the question most clearly relates to concern about appearance. Anxiety is inaccurate because there is a physical focus for the problem: melasma. The client has decreased social engagements, but there is no indication that she has excluded all activities. There are insufficient data to support the inability to carry out expected roles.

A nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which one of the following becomes apparent?

*1. Decreased periods of uterine relaxation between contractions* 2. Dilation of the cervix of greater than 1 and less than 5 cm/hr during the active phase 3. Descent of less than 1 to 2 cm/hr 4. Latent phase of less than 6 hours *Rationale:* A sign of a possible need for emergency intervention is inadequate uterine relaxation between contractions. Inadequate relaxation interferes with the transfer of oxygen and nutrients to the fetus through the mother's placenta. All other options are within normal limits for a nulliparous woman. By definition a precipitate labor lasts less than 3 hours.

A primigravida's membranes rupture spontaneously. The nurse's first action is to:

*1. Determine the fetal heart rate.* 2. Prepare for immediate delivery. 3. Monitor the contraction pattern. 4. Note the amount, color, and odor of the amniotic fluid. *Rationale:* When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the contraction pattern and noting the amount, color, and odor of the amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery.

The advantages of using spinal anesthesia for delivery of a fetus include which of the following? *Select all that apply.*

*1. Ease of administration* *2. Absence of fetal hypoxia* *3. Immediate onset of anesthesia* 4. Blockade of sympathetic fibers 5. Increased voluntary expulsive efforts 6. Decreased incidence of bladder atony *Rationale:* Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include onset of anesthesia in 1 to 3 minutes, ease of administration, and absence of fetal hypoxia. A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

In the prenatal clinic, a nurse is gathering data from a new client for the health history information. What is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

*1. Establish a therapeutic relationship between the nurse and pregnant client.* 2. Use specific closed-ended questions. 3. Omit this area of questions because they are highly personal. 4. Apologize for the embarrassment that these questions may cause the client. *Rationale:* The initial data collection interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned, purposeful communication that focuses on specific content. Options 2, 3, and 4 are incorrect and would not elicit correct client responses.

A nurse assisting to monitor a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client to reflect an attitude of:

*1. Excitement* 2. Helplessness 3. Irritability 4. Seriousness *Rationale:* In early labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth. Options 2, 3, and 4 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?

*1. Expression of hope for a positive outcome* 2. Delaying preparations for finishing the nursery at home 3. Walking 1 to 2 miles daily 4. Anticipatory grieving *Rationale:* Hoping for a positive outcome is an appropriate coping mechanism. It is important to support an expression of hope by a client with a high-risk pregnancy as long as the hope is realistic (e.g., fetus is viable). Anticipatory grieving is not a positive adaptation for this client. Grieving should begin when a loss occurs. Delaying nursery preparations at home reflects a "expecting the worst" situation. Walking 1 to 2 miles daily is contraindicated for a woman with GH.

A nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the health care provider. Choose the warning signs that the nurse places on the list. *Select all that apply.*

*1. Facial edema* *2. Rapid weight gain* *3. Visual disturbances* *4. Generalized edema* 5. Nausea on arising in the morning 6. The presence of irregular painless contractions *Rationale:* Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, regular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

A nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following most appropriately describes the mother's problem at this time?

*1. Fear about what is happening* 2. Lack of control over the situation 3. Inability to cope 4. Deficient sensory perception *Rationale:* The mother is anxious and frightened and the most appropriate problem for the client at this time is fear about what is happening. No data in the question support the problems noted in the other options; although they may be a consideration for this client at some point during the hospitalized experience.

A nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which of the following psychosocial issues?

*1. Feelings of guilt are often associated with grief.* 2. Grief and loss are usually resolved within 3 months. 3. The amount of pain and discomfort as a result of the abortion 4. The other children in the family and the ability to bear children in the future *Rationale:* Nurses must consider the psychological needs of the family experiencing spontaneous abortion. Grief often includes feelings of guilt. The grieving process is individual and may last a year or longer. It is not appropriate to focus on the client's ability to have other children. The amount of pain and discomfort is important, but this is a physiological concern.

A nurse is monitoring a client at risk for placental abruption. Which of the following is indicative of this complication?

*1. Fetal distress* 2. A soft abdomen 3. Painless bleeding 4. Normal blood pressure *Rationale:* Signs of placental abruption include a tender, rigid abdomen; pain; severe, dark red vaginal bleeding; maternal shock (hypotension); and fetal distress. The other options are incorrect.

A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which of the following findings would indicate a need to contact the registered nurse (RN)?

*1. Fetal heart rate of 180 beats per minute* 2. White blood cell count of 12,000/mm3 3. Maternal pulse rate of 85 beats per minute 4. Hemoglobin of 11 g/dL *Rationale:* A normal fetal heart rate is 120 to 160 beats per minute. A count of 180 beats per minute could indicate fetal distress and needs to be reported. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 18,000/mm3. During the immediate postpartum period the count may range from 25,000 to 30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The total blood volume increases 30% to 50% by the end of the second trimester. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.

A nurse is assisting in performing Leopold's maneuvers. When the client asks what these are for, the nurse's best response is that these maneuvers help to determine:

*1. Fetal position* 2. Fetal heart rate 3. Duration of contractions 4. Frequency of contractions *Rationale:* Leopold's maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal position and presentation. Options 2, 3, and 4 are incorrect.

A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted?

*1. Fetal tachycardia* 2. Increased urinary output 3. Contractions occurring every 3 minutes 4. Soft uterine tone palpated between contractions *Rationale:* Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia because of excessive uterine activity. The nurse should also ensure that the uterus maintains an adequate resting tone between contractions. Options 2, 3, and 4 are not indications of a problem.

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? *Select all that apply.*

*1. Flushing* 2. Hypertension 3. Increased urine output *4. Depressed respirations* *5. Extreme muscle weakness* 6. Hyperactive deep tendon reflexes *Rationale:* Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

A nurse is collecting data on a client who is pregnant with twins. Which of the following signs would alert the nurse to a potential problem specifically related to the twin pregnancy?

*1. Hypertension* 2. Elevated blood glucose levels 3. Uterine size is large for gestational age 4. Mother is confirmed as blood type Rh negative *Rationale:* The mother with a multiple-gestation pregnancy is at a higher risk for preeclampsia than if she had a singleton pregnancy. Mother should be monitored for signs and symptoms of preeclampsia and preterm labor. A classic sign of preeclampsia is hypertension. An elevated blood glucose level and Rh sensitization are concerns but are not unique to a multiple pregnancy. Uterine size may be large for gestational age in a multiple-gestation pregnancy.

A 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 of the following is an unassociated finding with this diagnosis?

*1. Hypotension* 2. Vaginal bleeding 3. No fetal heart activity 4. Elevated levels of human chorionic gonadotropin (HCG) *Rationale:* The most common signs and symptoms of gestational trophoblastic disease include elevated levels of HCG, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of gestational hypertension. An elevated blood pressure would also be noted.

During the antenatal period of a client diagnosed with the human immunodeficiency virus (HIV), the nurse weighs and plots the weight gain pattern routinely and discusses the findings. The primary purpose of this action is to:

*1. Identify appropriate fetal development.* 2. Document trends in weight gain patterns. 3. Observe for early signs of gestational hypertension. 4. Recognize problems with the women's weight gain. *Rationale:* Pregnant HIV positive clients are at risk for alterations in nutrition, especially less than body requirements. Plotting weight gain patterns throughout pregnancy will help support adequate fetal development while reassuring the client that a safe environment is being promoted for her developing fetus. The remaining options are not specific to this client.

A 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?

*1. Increased blood volume of the mother during pregnancy* 2. Decreased metabolism of iron during pregnancy 3. Decreased maternal hemoglobin formation 4. Poor intake of iron-rich foods *Rationale:* During the later part of the first trimester, the blood volume of the mother increases more rapidly than blood cell production, leading to a decrease in the concentration of hemoglobin and erythrocytes. This is a normal process that causes a physiological anemia of pregnancy, or hemodilution. There is an increased metabolism of iron and maternal hemoglobin formation. The poor intake of iron-rich foods may cause an anemic condition, but physiological anemia of pregnancy occurs as a result of increased blood volume of the mother during pregnancy.

A nurse assisting in the care of a woman in labor should focus primarily on which of the following at the time of delivery?

*1. Infant* 2. Mother 3. Support person 4. Primary health care provider *Rationale:* The nurse's primary responsibility at the time of delivery is focused on the infant. The primary health care provider is primarily responsible for the care of the mother. The support persons are responsible for themselves.

A pregnant client asks the prenatal clinic nurse what the fetal period of development means? The nurse tells the woman that the fetal period is the:

*1. Longest period of fetal development* 2. First 3 days of fetal development following conception 3. First 2 weeks of fetal development following conception 4. Fetal development beginning the third week after conception through the eighth week *Rationale:* The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form. The pre-embryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period.

A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. The nurse tells the woman that the purpose of progesterone is to:

*1. Maintain the uterine lining for implantation.* 2. Stimulate metabolism of glucose and convert the glucose to fat. 3. Prevent the involution of the corpus luteum and maintain the production of progesterone until the placenta is formed. 4. Stimulate uterine development to provide an environment for the fetus, and stimulate the breasts to prepare for lactation. *Rationale:* Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

A nurse is collecting data from a client who is pregnant with twins. The nurse understands that which of the following complications is likely associated with a twin pregnancy?

*1. Maternal anemia* 2. Postterm labor 3. Oligohydramnios 4. Gestational diabetes *Rationale:* Maternal anemia occurs in a client pregnant with twins because the maternal system is nurturing more than one fetus. Preterm labor, rather than postterm labor is likely to occur. Hydramnios may be associated with a twin pregnancy as a result of increased renal perfusion from cross-vessel anastomosis with monozygotic twins. Option 4 is not a complication of a twin pregnancy.

The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client?

*1. Measuring the fundal height* 2. Attaching electronic fetal monitoring 3. Preparing the client for a possible cesarean section 4. Gathering equipment for starting an intravenous line *Rationale:* Option 1 is a low priority, because fundal height should be measured at each antepartal clinic visit; it is not a priority of care during the intrapartum period. Options 2, 3, and 4 are all high priorities. The twins should be monitored by dual electronic fetal monitoring, and any signs of distress should be reported. Many health care providers choose to perform a cesarean birth if either of the twins is breech. The mother should have an intravenous line in place in case fluid or blood replacement is required.

A nurse is reviewing the health care record of a pregnant client at 16 weeks' gestation. The nurse would expect documentation that the fundus of the uterus is noted at which of the following areas?

*1. Midway between the symphysis pubis and the umbilicus* 2. At the umbilicus 3. Just above the symphysis pubis 4. At the level of the xiphoid process *Rationale:* At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.

A nurse assigned to care for a client with mild preeclampsia would anticipate which specific nursing intervention for this client?

*1. Monitoring fetal movement* 2. Maintaining complete bedrest 3. Monitoring daily blood glucose 4. Restricting maternal fluid intake *Rationale:* A client with mild preeclampsia can be managed at home. The expectant mother is asked to keep a record of fetal movements. Bedrest with bathroom privileges is prescribed. Urine is checked for protein. A blood glucose test is not necessary. The client usually follows a regular diet that does not restrict fluids.

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. *Select all that apply.*

*1. Oliguria* 2. Seizures 3. Contractions *4. Proteinuria 3+* 5. Muscle cramps *6. Blood pressure 168/116 mm Hg* *Rationale:* Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

A nurse is providing instructions to a client about preterm labor. The nurse would do which of the following as the effective method for teaching the client to monitor for preterm uterine contractions?

*1. Palpate for uterine contractions at the same time as the client.* 2. Provide a simple pamphlet with multiple illustrations. 3. Ask about contractions at each visit. 4. Attach the monitor to the client's abdomen and have her palpate at the same time. *Rationale:* Option 1 uses teaching and learning principles. It includes the most direct way to determine the level of client understanding. The client may not be able to read well. The client may not understand what to feel for with contractions and may answer only to please the nurse. A monitor would be cost prohibitive and does not give human feedback.

A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse take first?

*1. Place the client in the Trendelenburg position.* 2. Obtain the equipment to insert an intravenous (IV) line. 3. Palpate and evaluate contractions while calling the health care provider. 4. Place the woman in either a side-lying position or high-Fowler's position. *Rationale:* When an umbilical cord is protruding, nursing actions are directed at reducing cord compression and facilitating delivery of the fetus. The client should be placed in extreme Trendelenburg, Sims', or knee-chest position to reduce cord compression. The health care provider is notified, and an IV is started after initiating emergency care for the client.

A nurse is caring for a woman in the delivery room. The health care provider prescribes an oxytocic medication for the woman to stimulate uterine contractions and prevent hemorrhage. The nurse understands that this medication will be administered after delivery of the:

*1. Placenta* 2. Infant's body 3. Infant's head 4. Infant's shoulders *Rationale:* Oxytocics are administered because they stimulate the uterus to contract, thereby helping prevent hemorrhage after the placenta is expelled. If an oxytocic medication is prescribed, the nurse administers the medication after the placenta has been expelled. If the medication is given before the delivery of the placenta, it can cause the uterus to contract more forcefully and restrict delivery.

A nurse should prepare to give a prescribed oxytocic medication after delivery of the:

*1. Placenta* 2. Infant's body 3. Infant's head 4. Infant's shoulders *Rationale:* Oxytocics are administered because they stimulate the uterus to contract, thereby helping to prevent hemorrhage after the placenta is expelled. If an oxytocic medication is prescribed, the nurse administers the medication after placental delivery.

A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. The nurse immediately:

*1. Places a gloved hand into the vagina and holds the presenting part off of the umbilical cord* 2. Transports the client to the delivery room 3. Gently pushes the cord into the vagina 4. Summons for help from other staff members *Rationale:* When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should also place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. The nurse should summon for help, and other staff members should contact the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is also administered to the mother to increase fetal oxygenation.

A nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?

*1. Potential for infection* 2. Inability to tolerate activity 3. Inability to perform hygiene measures independently 4. Inability to maintain adequate nutritional intake *Rationale:* Clients with HIV often show some evidence of immune dysfunction and may have increased vulnerability to infection. Although the client may need assistance with hygiene measures and may have difficulty tolerating activity, these are not the priority. Although imbalanced nutrition is a concern, infection is specifically related to HIV and is a priority.

A nurse caring for a client diagnosed with placental abruption would plan to:

*1. Prepare the client for a cesarean birth.* 2. Administer frequent enemas until clear. 3. Prepare the client for a stress test. 4. Reposition the client to the left side. *Rationale:* Early diagnosis of placental abruption is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood work analysis, and either an immediate cesarean birth or vaginal delivery, if possible. The incorrect options are not helpful in managing this problem.

A nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which of the following would the nurse check first?

*1. Pulse* 2. Weight 3. Temperature 4. Abdominal girth measurement *Rationale:* The primary concern when ectopic pregnancy is suspected is the occurrence of bleeding and hypovolemic shock. Option 1 is the only assessment that would provide information related to this occurrence. An elevated pulse is an indicator of shock. The nurse should also monitor for decreasing hematocrit levels and pain. Options 2, 3, and 4 do not provide data that would indicate the occurrence of hypovolemic shock.

During an initial prenatal visit, the nurse notes that the client's hemoglobin level is indicative of iron deficiency anemia. Which additional client data would also support this finding?

*1. Reports of fatigue* 2. Pink mucous membranes 3. Increased vaginal secretions 4. Increased frequency of voiding *Rationale:* Anemia is a common problem in pregnancy and is characterized by a hemoglobin level of less than between 10.5 and 11 g/dL. Iron deficiency anemia and folic acid deficiency are two common types of anemia that present a concern during pregnancy. Although fatigue may be seen in some pregnant women, its presence may reflect complications caused by decreased oxygen supply to vital organs, thus supporting the laboratory findings. The other options are normal observations during pregnancy.

A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid (INH) and rifampin (Rifadin). The nurse plans to implement which intervention?

*1. Reviewing daily nutritional intake with the client* 2. Encouraging the client to stop taking medications during the last trimester of pregnancy 3. Informing the client that follow-up care after delivery will not be needed 4. Reinforcing that infants are usually not susceptible to TB infection *Rationale:* Social conditions placing pregnant women at risk for TB include poverty, crowded living conditions, and malnutrition. In the case of acute disease during the antenatal period, a 9-month course of isoniazid and rifampin is suggested. Follow-up sputum screenings and evaluations are essential to establish treatment effectiveness post-delivery. Teaching the client about the importance of an adequate nutritional intake needs to be included in the home care instructions. The remaining options do not contain correct information.

A nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? *Select all that apply.*

*1. Signs of fetal distress* *2. High level of maternal anxiety* *3. Failure of the fetus to descend* 4. Leaking of a clear liquid from the vagina 5. Progressive but slow changes in the cervix *Rationale:* Fetal distress, failure to descend, and extreme maternal anxiety are consistent with the findings that occur with dystocia. Progressive changes in the cervix are a reassuring pattern in labor while leaking amniotic fluid is a normal occurrence.

A nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse would first:

*1. Stop the oxytocin infusion.* 2. Check the client's blood pressure. 3. Check the client for bladder distention. 4. Place the client in a knee-chest position. *Rationale:* Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse would intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped. In addition, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The registered nurse is immediately notified and will then contact the health care provider. The nurse would monitor the client's blood pressure and monitor intake and output. However, the nurse would first stop the infusion.

A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to:

*1. Strengthen the pelvic floor in preparation for delivery.* 2. Prevent urinary tract infections. 3. Reduce a backache. 4. Prevent ankle edema. *Rationale:* Kegel exercises will assist to strengthen the pelvic floor. Pelvic tilt exercises will help reduce backaches. Instructing a client to drink 8 ounces of fluids six times a day will help prevent urinary tract infections. Leg elevation will assist in preventing ankle edema.

A nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which of the following findings is least likely associated with DIC?

*1. Swelling of the calf of one leg* 2. Prolonged clotting times 3. Decreased platelet count 4. Petechiae, oozing from injection sites, and hematuria *Rationale:* DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. Petechiae, oozing from injection sites, and hematuria are associated with the presence of DIC. Swelling and pain in the calf of one leg more likely are associated with thrombophlebitis.

A nurse is reviewing the health history of a pregnant client. Which of the following data, if noted in the client's health history, would indicate a risk for spontaneous abortion?

*1. Syphilis* 2. Age of 45 years 3. Diabetes mellitus 4. Inactive genital herpes *Rationale:* Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is inconclusive evidence that genital herpes is a causative agent in abortion. Maternal age older than 40 years and diabetes mellitus are considered high risk factors in a pregnancy, increasing the risk of congenital malformations.

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which of the following laboratory studies would further support the presence of HIV?

*1. T lymphocyte levels* 2. Angiotensin levels 3. Glomerular filtration rate 4. Platelet count *Rationale:* HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney. Glomerular filtration rate indicates kidney function. Platelet count is important and may be an indicator of HIV, but this laboratory test already has been identified in the data of the question.

The plan of care for a pregnant teen should include teaching regarding which of the following concerning dental care?

*1. Tell the dental office staff that she is pregnant.* 2. Avoid the use of local anesthetics during dental work. 3. Use toothpaste with baking soda to decrease plaque buildup. 4. Expect to lose at least one tooth because of calcium and phosphorus leaving the teeth to nourish the fetus. *Rationale:* Baking soda may irritate the gums, which are more likely to bleed because of hormonal changes of pregnancy. Local anesthetics for minor dental work should not have adverse effects on the fetus. Option 4 is inaccurate information. The dental staff needs to know about the pregnancy so that care is taken during examinations and x-ray studies are avoided.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client:

*1. That the bladder must be full during the exam* 2. That the bladder must be empty during the exam 3. She will be given RhoGAM because she is Rh positive 4. Not to eat or drink anything 4 to 6 hours before the exam *Rationale:* Before 20 weeks' gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks' gestation, the bladder should be emptied to minimize the chance of puncturing the placenta or fetus. Rho(D) immune globulin (RhoGAM) is administered to Rh-negative woman because of the risk of contact with the fetal blood during the exam. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the exam is an important intervention.

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse bases the response on which of the following?

*1. The breast changes are a result of the secretion of estrogen and progesterone.* 2. The breasts become stretched because of weight gain. 3. The increased metabolic rate causes the breasts to become larger. 4. Cortisol secreted by the adrenals plays a factor in increasing the size and appearance of the breasts. *Rationale:* During pregnancy the breasts change in both size and appearance. The increase in size is a result of the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin. Options 2, 3, and 4 are incorrect.

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem should direct care for this client?

*1. The client feels hopeless about the situation.* 2. The client lacks knowledge about the disease process. 3. The client lacks self-esteem from being ill. 4. The client is grieving because of her condition. *Rationale:* By seeing no way out of the situation except for death, the client is expressing hopelessness. A person who lacks hope feels that life is too much to handle. Option 2 is a possible problem later, but the question does not contain enough data to support it at this point. The data given does not support a lack of self-esteem. Grieving may be a possible problem at a later time; however, at this time, hopelessness should take precedence.

During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." The nurse needs to further check:

*1. The client for blood pressure changes and protein in the urine* 2. The client's height of the fundus as compared to the date of her last visit 3. The blood glucose level 4. For any vaginal discharge *Rationale:* Finger edema is a frequent forerunner of gestational hypertension and should be investigated further. Options 2, 3, and 4 are indicators of other problems such as molar pregnancy, diabetes, or infections.

A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem should initially direct nursing care at this time?

*1. The client is blaming herself.* 2. The client lacks knowledge regarding diabetes treatment. 3. The client is concerned about her appearance. 4. The client is experiencing fetal distress. *Rationale:* The client is putting the blame for the diabetes on herself. She is expressing fear and grief. There is no data in the question that indicates that the client lacks knowledge about diabetes treatment, is concerned about appearance, or is experiencing fetal distress.

A nurse is preparing to instruct a pregnant client about nutrition. The nurse plans to include which of the following in this client's teaching plan?

*1. The nutritional status of the mother significantly influences fetal growth and development.* 2. All mothers are at high risk for nutritional deficiencies. 3. Calcium is not important until the third trimester. 4. Iron supplements are not necessary unless the mother has iron deficiency anemia. *Rationale:* Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements are prescribed routinely.

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse provides a list of instructions for the client regarding management of care. Choose the instructions that the nurse places on the list. *Select all that apply.*

*1. To note the color of blood on each perineal pad* *2. To watch for the evidence of the passage of tissue* *3. To note the quantity of blood on each perineal pad* *4. To count the number of perineal pads used on a daily basis* 5. To avoid any sexual activity for the remainder of the pregnancy 6. To maintain strict bedrest throughout the remainder of the pregnancy *Rationale:* The preference of the individual woman should be the deciding factor as to whether she rests in bed. Some women may wish to rest, and they should be encouraged to do whatever feels best for them. Strict bedrest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the health care provider or nurse-midwife. The woman is instructed to count the number of perineal pads used on a daily basis and to note the quantity and color of blood on the pad. The woman should also watch for the evidence of the passage of tissue.

A nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?

*1. Turn client to her side and administer oxygen by mask at 8 to 10 L/min.* 2. Turn client to her back and administer oxygen by mask at 8 to 10 L/min. 3. Turn client to her side and administer oxygen by nasal cannula at 2 to 4 L/min. 4. Turn client to her back and administer oxygen by nasal cannula at 2 to 4 L/min. *Rationale:* Prompt treatment must be initiated when the FHR begins to slow or a loss of variability is identified during labor. To facilitate oxygenation of the mother and fetus, the mother is turned to her side to reduce uterine pressure on the ascending vena cava and descending aorta. The greater flow rate for oxygen is also indicated.

A nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should:

*1. Turn the client onto her left side.* 2. Instruct the client to lie in a prone position. 3. Place the client in a prone position with the head of the bed elevated. 4. Have the client stand for the procedure. *Rationale:* When measuring fundal height, the client lies in a supine position, and the nurse instructs the woman to turn onto her left side. The nurse then elevates the left buttock by placing a pillow under the area. This position will assist in preventing supine hypotension. Options 2, 3, and 4 are incorrect client positions for measuring fundal height.

A nurse is collecting initial data on a newborn in the delivery room. Which observation would the nurse expect to note when examining the umbilical cord of the newborn?

*1. Two arteries and one vein* 2. Two veins and one artery 3. One artery and one vein 4. Two arteries and two veins *Rationale:* The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo.

A clinic nurse is teaching a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the health care provider. Which of the following would be included on the list? *Select all that apply.*

*1. Visual disturbances* *2. Rapid weight gain* *3. Generalized or facial edema* 4. Irregular, painless contractions *5. Vaginal bleeding* 6. The presence of fetal activity *Rationale:* Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal irregular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, a change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

A 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 this area?

*1. Vulva* 2. Fingers 3. Around the eyes 4. Around the abdomen *Rationale:* Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion.

A nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which of the following areas, knowing that venous congestion is most commonly noted here?

*1. Vulva* 2. Fingers 3. Around the eyes 4. Around the abdomen *Rationale:* Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion most commonly is noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be associated directly with venous congestion.

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

*5* *Rationale:* The fetal heart is beating and has developed four chambers by gestational week 5.

A pregnant client asks a 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:

1. 6 and 8 weeks of gestation 2. 8 and 10 weeks of gestation 3. 12 and 14 weeks of gestation *4. 16 and 20 weeks of gestation* *Rationale:* Fetal movement, called "quickening," is not perceived until the second trimester. Between 16 and 20 weeks of gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity.

A nurse provides instructions to a client with mild preeclampsia on home care. The nurse evaluates that the teaching has been effective when the client states:

1. "As long as the health nurse is visiting me daily, I do not have to keep my next health care provider's appointment." 2. "I need to take my blood pressure each morning and alternate arms each time." 3. "I need to check my weight every day at different times during the day." *4. "I need to check my urine with a dipstick every day for protein and call the health care provider if it is 2+ or more."* *Rationale:* Option 4 is a correct statement. It is still important to keep health care provider appointments to monitor for any other physical changes in the mother or baby. Blood pressure must be taken in the same arm, in a sitting position, every day to obtain a consistent and accurate reading. The weight must be checked at the same time each day under the following conditions to obtain reliable weights: client wearing the same clothes, after client voids, and before client eats breakfast.

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client states:

1. "Breast-feeding after delivery is best for my baby." 2. "I can continue to hug and hold my other children." 3. "It may be 2 years before I know if my baby has HIV." 4. "My husband and I can still sleep together in the same bed." *Rationale:* Breast-feeding is contraindicated if the mother is positive for HIV because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertain that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV.

A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, what would be the estimated date of delivery (EDD)?

1. January 21 *2. January 12* 3. January 19 4. December 19 *Rationale:* Nägele's rule is a noninvasive method of calculating the EDD as follows: subtract 3 months, add 7 days to the first day of the LMP, and add 1 year as appropriate. This is based on the assumption that the cycle is 28 days. April 5 plus 7 days minus 3 months is January 12.

A 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 response by the nurse indicates a lack of understanding of the implications of the client's symptoms?

1. "Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?" 2. "Palpate for contractions and call back if there are more than four contractions in the next hour." *3. "This is probably an emergency. Have someone drive you to a hospital now."* 4. "Lie on your left side for an hour and try to drink 'some fluids." *Rationale:* If a client experiences uterine activity, it may be helpful to have her lie on the left side and drink fluids to reduce uterine hypoxia and activity. It may also be helpful to keep the bladder empty. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation. The information presented in the question does not represent an emergency at this time, but it requires further monitoring.

A pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. Which nursing response would best support the client?

1. "Don't worry about your baby. Complications are rare." 2. "You will not have any problems if you follow all the advice the health care provider has given you." 3. "Your baby will need to spend a few days in the neonatal intensive care unit following delivery." *4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."* *Rationale:* The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options 1 and 2 provide a false reassurance to the client. Option 3 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

A nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student states:

1. "FSH and LH are secreted by the adrenal glands." *2. "FSH and LH are released from the anterior pituitary gland."* 3. "FSH and LH are secreted by the corpus luteum of the ovary." 4. "FSH and LH stimulate the formation of milk during pregnancy." *Rationale:* FSH and LH are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the Graafian follicle, and production of progesterone. Options 1, 3, and 4 are incorrect.

When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?

1. "Have you been sexually active during the pregnancy and, if so, with how many different partners?" 2. "Have you experienced any high fevers or unusual rashes during the first 6 weeks of your pregnancy?" 3. "Have you been recently exposed to children with draining skin rashes or gastrointestinal symptoms?" *4. "Do you have any cats as house pets, and, if so, do you ever come in contact with their soiled kitty litter?"* *Rationale:* Toxoplasmosis is a systemic, usually asymptomatic illness caused by the protozoal parasite. Humans acquire the infection from inadequately cooked meat, eggs, or milk or from ingesting or inhaling the oocyst stage of the parasite excreted in feline feces in contaminated soil or kitty litter. The remaining options are not related to this disease.

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that goal achievement has occurred when the client states which of the following?

1. "I am eating three servings of cracked-wheat bread each day." *2. "I am eating fresh fruits and vegetables for snacks and for dessert each day."* 3. "I am drinking 8 ounces of water with each meal." 4. "I eat two saltine crackers before I get up each morning." *Rationale:* Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Cracked-wheat bread may abrade the tender gums; drinking water with meals has no direct effect on gums; saltine crackers before arising helps decrease nausea.

A nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client would alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?

1. "I am not crazy about eating vegetables but I will do my best." *2. "I need to gain only ten pounds so that my baby will be small like I am."* 3. "I don't like milk but I can drink it if it is in a shake mixed with chocolate." 4. "I really like to have a root beer float with vanilla ice cream in the afternoon." *Rationale:* Pregnant adolescents are at higher risk for complications than are other pregnant clients. Adolescents are often concerned about their body image. If weight is a major focus, the adolescent is more likely to restrict calories to avoid weight gain. Option 2 is the only response that suggests a possible concern. Options 3 and 4 indicate that the client will consume items that will help increase calcium intake. Option 1 expresses an attempt to consume required vegetables.

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states:

1. "I can eat more sweets now, because I need more calories." 2. "I need more fat in my diet so that the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." *4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."* *Rationale:* An increase in calories is needed during pregnancy, but concentrated sugars should be avoided, because they may cause hyperglycemia. The fat intake should be 20% to 30% of the total calories. The client with diabetes needs about 50% to 60% of her caloric intake from carbohydrates and about 12% to 20% from protein. High-fiber foods will control blood glucose levels and prevent constipation.

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 states:

1. "I know I can never have another child." 2. "I am glad I won't have to have these shots if I have another child." 3. "I will have to have an injection once a month until the baby is born." *4. "I will tell the nurse at the hospital that I had RhoGAM during pregnancy."* *Rationale:* As described in the question, it is accepted practice to administer Rho(D) immune globulin (RhoGAM) to an Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated, because the immunity is passive. Options 1, 2, and 3 are inaccurate information.

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands about this infection when the client says:

1. "I know my baby will be immune from hepatitis for the first 2 months of life." 2. "I feel sad that my baby is going to be isolated in the nursery after my delivery." 3. "Hepatitis B will cause a severe eye infection in my baby." *4. "I am so glad that I can breast-feed my baby after she has been vaccinated."* *Rationale:* Although HBV is transmitted in breast milk, once serum immune globulin has been administered, the mother may breast-feed without risk to the newborn. Option 1 is incorrect. To reduce the possibility of hepatitis B virus being spread to the newborn, neonates routinely are vaccinated at birth. Options 2 and 3 are incorrect.

A perinatal client with a history of heart disease has been instructed on care at home. Which of the following statements if made by the client would indicate the need for further instructions?

1. "I need to avoid people with infections." 2. "I should avoid stressful situations." 3. "I need to watch for weight gain." *4. "It is best to rest on my right side."* *Rationale:* Stress causes increased cardiac workload. Too much weight gain causes an increase in body requirements and stress on the heart. To avoid infections, visitors with active infections should not be allowed to visit the client. It is best to rest on the left side to promote blood return.

A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?

1. "I should avoid the use of condoms." 2. "I can douche any time I want." 3. "I can wear my tight-fitting jeans." *4. "I should choose underwear with a cotton panel liner."* *Rationale:* Condoms should be used to minimize the spread of sexually transmitted infectious diseases. Wearing tight clothes irritates the genital area and does not allow for air circulation. Douching is to be avoided. Wearing items with a cotton panel liner allows for air movement in and around the genital area.

A nurse employed in a health care provider's office is collecting information from a pregnant client. Which of the following statements made by the client likely indicates the need for psychological referral?

1. "I will never be able to lose my weight and regain a great figure. I feel ugly." 2. "I don't like the way I look. My husband could never find me attractive again." *3. "I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."* 4. "I have terrible mood swings. I will be glad when this is all over." *Rationale:* Options 1, 2, and 4 are feelings about self and body image that many women express during pregnancy. The statement in option 3 is much stronger and places blame on the fetus. The direction of anger to the fetus should be explored. The nurse may find that a psychological referral is appropriate.

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?

1. "I'm getting tired of lying flat on my back." 2. "I shut the machine off when I talk on the telephone." *3. "What an efficient way to record my baby's heart rate."* 4. "How many volts of electricity are going through my body?" *Rationale:* EFM is a method of recording the fetal heart rate. The woman is asked to assume a semi-sitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface; in this case, the fetal heart and valves. No electricity or voltage goes through the body. EFM does not need to be shut off when talking on the telephone.

A nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client says:

1. "I'm having bloody show." *2. "My cervix is completely dilated."* 3. "My membranes are now ruptured." 4. "The contractions are intense." *Rationale:* The second stage of labor begins when the cervix is completely dilated and ends with the birth of the infant. Options 1, 3, and 4 can occur any time in labor.

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, the nurse determines that the best response would be which of the following?

1. "If you do not eat regular meals, you will hurt your baby." *2. "Can you tell me more about what you are eating?"* 3. "I'll have the health care provider review your diet history." 4. "It does not matter anymore how much weight you gain." *Rationale:* It is important for the nurse to obtain additional information from the client. In option 2, the nurse is using the therapeutic communication tool of validation and clarification in order to obtain more information. The other options will block communication. Option 1 devalues the client and shows disapproval. Option 3 is avoiding the subject, and option 4 provides false reassurance.

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning?

1. "Iron supplements will give me diarrhea." *2. "The iron is needed for the red blood cells."* 3. "Meat does not provide iron and should be avoided." 4. "My body has all the iron it needs, and I don't need to take supplements." *Rationale:* A nutritional supplement that is commonly needed during pregnancy for the red blood cells is iron. Anemia of pregnancy is primarily caused by iron deficiency. Iron supplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal serum.

A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term?

1. "It is the thinning of the lower uterine segment." *2. "It is the fetal movement that is felt by the mother."* 3. "It is irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." *Rationale:* Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks of gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, known as "uterine souffle" and is due to the blood circulation to the placenta and corresponds to the maternal pulse. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called "Hegar's sign."

Magnesium sulfate is prescribed for a client with severe preeclampsia. Which statement by the student nurse supports the need for further education regarding the action of this medication?

1. "It produces flushing and sweating as a result of decreased peripheral blood pressure." 2. "It decreases the central nervous system responses, acting as an anticonvulsant." *3. "It increases acetylcholine and blocks neuromuscular transmission."* 4. "It decreases the frequency and duration of uterine contractions." *Rationale:* Magnesium sulfate produces flushing and sweating as a result of decreased peripheral blood pressure; decreases the central nervous system responses and acts an anticonvulsant; decreases the frequency and duration of uterine contractions; and decreases acetylcholine, blocking neuromuscular transmission.

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone?

1. "It softens the muscles and joints of the pelvis." 2. "It is the primary hormone of milk production." *3. "It increases during pregnancy to stimulate basal metabolic rate."* 4. "It maintains the uterine lining for implantation." *Rationale:* Thyroxine increases during pregnancy to stimulate basal metabolic rates. Relaxin is the hormone that softens the muscles and joints of the pelvis. Prolactin is the primary hormone of milk production. Progesterone maintains uterine lining for implantation and relaxes all smooth muscle including the uterus.

A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which of the following responses, if made by the student, indicates an understanding of the function of this hormone?

1. "It softens the muscles and joints of the pelvis." 2. "It is the primary hormone of milk production." 3. "It increases during pregnancy to stimulate the basal metabolic rate." *4. "It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."* *Rationale:* Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus. Relaxin is the hormone that softens the muscles and joints of the pelvis during labor. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production.

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." The appropriate response by the nurse is which of the following?

1. "The health care provider is all set to go and cannot change plans now." 2. "You need to listen to your health care provider; he knows what he is doing." *3. "Tell me what you mean when you say that your baby has moved."* 4. "That would be impossible because babies don't move around this late." *Rationale:* Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 3 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 1, 2, and 4 do not and are blocks to communication.

Abdominal ultrasonography is prescribed for a woman who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement to the woman?

1. "The procedure will take about one hour." 2. "You will be positioned on your side with your head flat." 3. "You need to be sure to urinate before the procedure." *4. "You will be positioned on your back and turned slightly to one side with your head elevated."* *Rationale:* The client is positioned on the back with the head and the knees supported by pillows. The client's head will be elevated, and the client will be turned slightly to one side to prevent supine hypotension. The procedure takes 10 to 30 minutes. A full bladder makes it easier for sound waves to reach the pelvic area, so the client should be instructed to drink 1 to 2 quarts of clear fluid 1 hour before the test. The client should not void until the ultrasound is obtained. Options 1, 2, and 3 are incorrect.

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following informative statements will the nurse provide to the client?

1. "The test is an invasive procedure and requires that you sign an informed consent." 2. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." *3. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."* 4. "The fetus is challenged by uterine contractions to obtain the necessary information." *Rationale:* The nonstress test takes about 30 to 40 minutes. The test is termed "nonstress" because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded.

A nurse is instructing a pregnant client on dietary sources of iron. Which of the following food selections made by the client demonstrates an understanding of teaching?

1. Milk *2. Fresh spinach* 3. Potatoes 4. Cantaloupe *Rationale:* Dietary sources of iron include lean meats, liver, shellfish, dark green, leafy vegetables, such as spinach, legumes, whole grains and enriched grains, cereals, and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C.

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be appropriate?

1. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." 2. "Be sure to tell the doctor on your next prenatal visit, but there is little risk in the second trimester." 3. "You should avoid all school-age children during pregnancy." *4. "You were wise to call. I will check your rubella titer screening results and we can identify immediately if interventions are needed."* *Rationale:* Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. Rubella titer screening is a standard antenatal test for women during their initial screening. The results of this screening test need to be checked to determine if interventions are necessary. Options 1, 2, and 3 are inappropriate statements and do not address the subject of the question.

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client would indicate that the client understands her needs?

1. "There is no restriction on people who visit me." *2. "I should avoid stressful situations."* 3. "My weight gain is not important." 4. "I should rest on my back." *Rationale:* To avoid infections, visitors with active infections should not be allowed to visit the client. Stress causes increased heart workload. Too much weight gain causes an increase in body requirements and stress on the heart. Resting should be on the side to prevent vena cava syndrome (hypotensive syndrome) and to promote blood return.

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

1. "Urinary infections during pregnancy are common. Your baby will be fine." 2. "Your developing baby cannot acquire an infection from you during pregnancy." *3. "Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."* 4. "You shouldn't worry about this because you received early prenatal care and are taking your prenatal vitamins." *Rationale:* Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery. Appropriate antenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up repeat urine cultures. Option 3 is the only therapeutic response and is the response that identifies accurate information.

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following?

1. "Uterine contractions are stimulated by Leopold's maneuvers." 2. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." *3. "The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."* 4. "Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions." *Rationale:* A contraction stress test assesses placental oxygenation and function and determines the fetus' ability to tolerate labor as well as its well-being. The test is performed if the non stress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40 seconds or more during a 10-minute period have occurred. Frequent maternal blood pressure readings are performed, and the client is monitored closely while increasing doses of oxytocin are given. Leopold's maneuvers are performed to locate the position of the fetus.

A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes?

1. "Well, I guess I will just have to deal with this." 2. "Oh, well, I guess this isn't the end of the world." *3. "I shouldn't have eaten so many sweets before I became pregnant."* 4. "I have heard that this type of diabetes is first discovered during pregnancy." *Rationale:* Gestational diabetes is not necessarily caused by eating too many sweets before pregnancy. Options 1 and 2 indicate a common normal response. Option 4 is an accurate statement. Option 3 is the only option that indicates a knowledge deficit.

A nurse shares with a pregnant client that the results of her rubella screening is positive. What is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?

1. "You are still susceptible to rubella, so your toddler should receive the vaccine." 2. "Children do not receive the rubella vaccine until they have had their fifth birthday." 3. "It is discouraged that children of pregnant women be vaccinated during the pregnancy." *4. "You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."* *Rationale:* A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to Rubivirus, and immunity to the virus has been achieved so it is safe to be exposed as through contract with a newly vaccinated child. Children should receive their rubella immunization according to schedule (12 to 15 months of age).

A pregnant client who is anemic tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?

1. "You will not have any problems if you follow all the advice the doctor has given you." 2. "Your baby will need to spend a few days in the neonatal intensive care unit following delivery." 3. "Don't worry about your baby; complications are rare." *4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure that you are providing the best nutrition and growth potential."* *Rationale:* The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options 1 and 3 provide a false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?

1. "Your baby will not have any problems if you follow all the advice the health care provider has given you during your pregnancy." 2. "Your baby will likely need to spend a few days in the neonatal intensive care unit for observation following delivery." 3. "I wouldn't worry about your baby's health; complications from this condition are generally rare." *4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."* *Rationale:* The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is:

1. 1 inch below the coccyx 2. 1 inch below the iliac crest *3. 1 cm above the ischial spines* 4. 1 fingerbreadth below the symphysis pubis *Rationale:* Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.

A client with severe preeclampsia is receiving magnesium sulfate by intravenous infusion. The nurse reviews the laboratory results, knowing that which value is a therapeutic magnesium level?

1. 1 mg/dL 2. 3 mg/dL *3. 6 mg/dL* 4. 11 mg/dL *Rationale:* The therapeutic range for magnesium sulfate is approximately 5 to 8 mg/dL. The remaining options are incorrect.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Considering the client's behavior, the nurse suspects she is dilated:

1. 1 to 2 cm 2. 3 to 4 cm 3. 5 to 7 cm *4. 8 to 10 cm* *Rationale:* During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately:

1. 10 weeks of gestation 2. 12 weeks of gestation 3. 14 weeks of gestation *4. 18 weeks of gestation* *Rationale:* The first recognition of fetal movements, or "feeling life," by the multiparous woman may occur as early as the 14th to 16th week of gestation. The nulliparous woman may not notice these sensations until the 18th week of gestation or later. The first recognition of fetal movement is called "quickening."

A nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document that the FHR is normal if which of the following were noted?

1. 105 beats per minute *2. 150 beats per minute* 3. 170 beats per minute 4. 180 beats per minute *Rationale:* The normal baseline fetal heart rate has a lower limit of 110 to 120 beats per minute and an upper limit of 150 to 160 beats per minute. Therefore options 1, 3, and 4 are incorrect.

A nurse is providing information to a pregnant woman about food items high in folic acid. Which of the following mid-afternoon snacks should be recommended to supply folic acid?

1. 1½ cup of yogurt 2. One medium banana *3. Nuts and green, leafy vegetables* 4. 1 cup milk with two graham crackers *Rationale:* Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four daily servings of foods rich in folic acid. The food items in option 3 contain folic acid. Milk and yogurt supply calcium. Bananas provide potassium.

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?

1. 22 cm *2. 28 cm* 3. 36 cm 4. 40 cm *Rationale:* During the second and third trimesters (18 to 30 weeks' gestation), the fundal height in centimeters approximately equals the fetus' age in weeks plus or minus 2 cm. At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and, at term, the fundus is at the xiphoid process.

A nurse is assisting in performing an assessment on a client who is at 32 weeks of gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?

1. 22 cm 2. 28 cm *3. 32 cm* 4. 40 cm *Rationale:* From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, it may be possible that more than one fetus is present.

A nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds to the client, knowing that the sex of the fetus can be visually recognizable as early as week:

1. 4 2. 6 3. 8 *4. 12* *Rationale:* By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Options 1, 2, and 3 are incorrect.

A nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at gestational week:

1. 5 2. 10 3. 16 *4. 20* *Rationale:* The fetal heart rate can first be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound device is used, the fetal heart rate can be detected as early as 10 weeks of gestation.

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:

1. 6 and 8 weeks' gestation 2. 8 and 10 weeks' gestation 3. 10 and 12 weeks' gestation *4. 16 and 20 weeks' gestation* *Rationale:* Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity. Options 1, 2, and 3 are incorrect; these gestational time frames are too early for quickening.

A nurse is collecting data on a pregnant client and is preparing to auscultate the fetal heart sounds. The nurse prepares to use a fetoscope, knowing that fetal heart sounds can be heard with a fetoscope by which week of gestation?

1. 8 to 10 weeks 2. 10 to 12 weeks 3. 14 to 16 weeks *4. 18 to 20 weeks* *Rationale:* Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks of gestation. Options 1, 2, and 3 are incorrect because the fetal heart sounds cannot be heard with a fetoscope at these gestational times.

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 of the following heart rates is noted?

1. 80 beats per minute 2. 100 beats per minute *3. 150 beats per minute* 4. 180 beats per minute *Rationale:* Fetal heart rate depends on gestational age. It is normally 160 to 170 beats per minute during the first trimester, but it slows with fetal growth to 110 or 120 (low end) to 160 (high end) beats per minute near or at term.

A nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which of the following findings would place the client at this risk?

1. A 26-year-old primigravida 2. A single-fetus pregnancy 3. A hemoglobin of 13.5 g/dL *4. A urinary tract infection* *Rationale:* One risk factor for preterm labor is the presence of a genitourinary infection. Although the connection is not clearly understood, one hypothesis involves the release of prostaglandins by the pathogens, which may contribute to the initiation of contractions. Other risk factors for preterm labor include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age less than 15 years or first pregnancy older than the age of 35.

A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

1. A 33-year-old gravida III *2. An adolescent with multiple heterosexual contacts* 3. A 25-year-old client with a history of spontaneous abortions 4. A multigravida with a history of repeat cesarean deliveries *Rationale:* Although all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors. The client profiles in options 1, 3, and 4 identify at-risk situations for a variety of obstetric risk factors but not necessarily HIV infection.

When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which of the following factors would the nurse consider being significant?

1. A client who is gravida VI that delivered 10 hours ago and has lost 450 mL of blood *2. A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago* 3. A client who is primigravida with mild preeclampsia 4. A client who is primigravida that delivered a 10-pound baby 3 hours ago *Rationale:* Dead fetus syndrome is considered a risk factor for DIC. Hemorrhage is a risk factor with DIC; however, a loss of 450 mL is not considered hemorrhage. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large baby is not considered a risk factor for DIC.

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:

1. A full bladder 2. Emotional instability 3. Insufficient iron intake *4. Compression of the vena cava* *Rationale:* Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem. Options 1, 2, and 3 are not the cause of the problem described in the question.

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 would consult with the dietitian to ensure which of the following?

1. A low-calorie diet to ensure the absence of weight gain *2. A diet that is high in fluids and fiber to decrease constipation* 3. A diet that is low in fluids and fiber to decrease blood volume 4. Unlimited sodium intake to increase the circulating blood volume *Rationale:* Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system. The absence of weight gain is not recommended during pregnancy. Diets that are low in fluid and fiber cause a decrease in blood volume, which in turn deprives the fetus of nutrients. Too much sodium could cause an overload to the circulating blood volume and contribute to the cardiac condition.

The nurse notes that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. What is the explanation for this increase?

1. A sign of the client's excitement about pregnancy 2. An indication of a cardiac problem 3. An indicator of preeclampsia *4. A normal finding* *Rationale:* Between 14 and 20 weeks, the pulse increases slowly, up 10 to 15 beats per minute, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases during the first half of pregnancy, returning to baseline in the second half of pregnancy. Although excitement may cause an increase in pulse rate, the likely cause is the combination of normal physiological changes that occur during pregnancy. The remaining options are not supported by the information given in the question.

A pregnant client has been diagnosed with placental abruption. The nurse caring for the client prepares the client for:

1. A stress test *2. A cesarean birth* 3. Internal uterine contraction monitoring 4. Frequent repositioning from the right to the left side *Rationale:* Early diagnosis of placental abruption is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood analysis, and either an immediate cesarean birth or vaginal delivery. Options 1, 3, and 4 are not helpful in managing this problem.

A nurse is caring for a client who was admitted to the maternity unit at 8:00 AM with contractions occurring every 2 minutes, lasting 1½ minutes, and is dilated 4 cm with a cervical effacement of 60%. At 10:30 AM, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which of the following?

1. Abruptio placentae 2. Placenta previa *3. Ruptured uterus* 4. Preterm labor *Rationale:* The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock caused by bleeding in the abdomen. The manifestations identified in the question are not characteristic of abruptio placentae, placenta previa, or preterm labor.

A nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

1. Adequate prenatal care 2. Appropriate maternal nutrition and weight gain 3. Spontaneous rupture of membranes 2 hours ago *4. History of substance abuse during this pregnancy* *Rationale:* Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include low socioeconomic status, poor prenatal care and nutrition, and a history of substance abuse during pregnancy. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection.

A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse includes which of the following in the plan of care?

1. Administer antibiotics. 2. Maintain complete bedrest. 3. Notify the neonatal resuscitation team. *4. Maintain continuous electronic fetal monitoring.* *Rationale:* Maternal and fetal well-being is monitored before and during oxytocin administration and includes monitoring fetal heart rate, uterine contractions and tone, and maternal blood pressure. No data in the question indicate the presence of maternal or fetal complications that would require antibiotics, complete bedrest, or notifying the neonatal resuscitation team.

A nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which of the following is the most important information for the nurse to document on the strip?

1. Age of client *2. Maternal vital signs* 3. Last menstrual period 4. A temporary interruption in recording *Rationale:* Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 1 and 3 are irrelevant.

A nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is a cephalic presentation. The nurse understands that this is:

1. An abnormal presentation 2. The least favorable presentation 3. A presentation associated with prolonged labor *4. The common presentation* *Rationale:* The cephalic presentation is more favorable than others and is the most common. Abnormal presentations result in prolonged labor and are likely to necessitate a cesarean birth.

A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur. The nurse bases the response on which of the following?

1. An increase in long-acting insulin is needed. 2. An increase in short-acting insulin is needed. *3. A steady increase in insulin will be needed.* 4. An oral hypoglycemic medication will be added to the regimen. *Rationale:* There is little change in insulin requirements during the first trimester of pregnancy. In the second and third trimesters, insulin requirements increase gradually, often doubling toward the end of pregnancy. Oral hypoglycemic medications pass through the placenta and may be teratogenic to the fetus. Intermediate- and short-acting insulins are usually prescribed together. Option 3 is the correct option.

A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother?

1. An oral hypoglycemic agent 2. NPH insulin on a daily basis *3. A 3-hour glucose tolerance test* 4. A sliding scale regular insulin dose *Rationale:* A maternal blood glucose measurement is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes. Options 1, 2, and 4 would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented.

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which of the following problems do the data best support?

1. Anxiety 2. Low self-esteem 3. Brain attack (stroke) *4. High risk for infection* *Rationale:* Women with anemia have a higher incidence of puerperal complications such as infection than do pregnant women with normal hematological values. No data in the question support options 1, 2, or 3.

A nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, the nurse should specifically monitor which of the following?

1. Apical heart rate 2. Degree of edema *3. Deep tendon reflexes* 4. Presence of pitting peripheral edema *Rationale:* Loss of reflexes is often the first sign of developing toxicity. The nurse should assess knee jerk (patellar tendon reflex) for evidence of diminished or absent reflexes. Although options 1, 2, and 4 may be components of the assessment, these are not specifically associated with this medication.

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes:

1. Are the organ of copulation 2. Are where the fetus develops *3. Are where fertilization occurs* 4. Secrete estrogen and progesterone *Rationale:* Each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization. Fertilization typically occurs near the boundary between the ampulla and the isthmus of the tube. The vagina is the organ of copulation, and the fetus develops in the uterus. Estrogen is a hormone that is produced by the ovarian follicles, the corpus luteum, the adrenal cortex, and the placenta during pregnancy. Progesterone is a hormone that is secreted by the corpus luteum of the ovary, the adrenal glands, and the placenta during pregnancy.

A nurse-midwife is performing an assessment on a pregnant client and is assessing the client for the presence of ballottement. The nurse who is assisting understands that the nurse-midwife will implement which to test for the presence of ballottement?

1. Assess the cervix for thinning. *2. Initiate a sudden tap on the cervix.* 3. Auscultate for fetal heart sounds. 4. Palpate the abdomen for fetal movement. *Rationale:* Near mid-pregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position. When the cervix is tapped, the fetus floats upward in the amniotic fluid. The examiner feels a rebound when the fetus falls down. Options 1, 3, and 4 are incorrect.

The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. The nurse should:

1. Assess the client's blood pressure and fetal heart rate more frequently now. *2. Continue to assess vital signs and fetal heart rate the same as before the nerve block.* 3. Monitor more closely for fetal heart rate decelerations and loss of variability. 4. Assess the client's pulse and respirations every 2 minutes for the next 20 minutes. *Rationale:* Pudendal nerve block may be used when an episiotomy is to be performed, if forceps or a vacuum extractor is to be used to facilitate birth, or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. Pudendal block does not change maternal hemodynamic or respiratory functions, vital signs, or the fetal heart rate because it is considered a local anesthetic. Therefore the nurse would continue to assess vital signs and fetal heart rate the same as before the nerve block.

A nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. The nurse would expect documentation that the fundus of the uterus is noted at which area?

1. At the umbilicus 2. Just above the symphysis pubis 3. At the level of the xiphoid process *4. Midway between the symphysis pubis and the umbilicus* *Rationale:* At 12 weeks of gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.

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 of the following areas?

1. At the umbilicus 2. Just above the symphysis pubis 3. At the level of the xiphoid process *4. Midway between the symphysis pubis and the umbilicus* *Rationale:* At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.

A nurse is collecting data from a client with placenta previa during an office visit. The nurse checks which of the following items as first priority?

1. Availability of support systems 2. Compliance with activity limitations *3. Signs of fetal distress* 4. Client's understanding of her condition *Rationale:* Although all of the options may be assessed, the safety of the mother-infant dyad is the priority. Signs of fetal distress is a primary concern, although the information gained through the other assessments may ultimately affect the well-being of the fetus.

A prenatal client with vaginal bleeding is admitted to the labor unit. Which of the following signs or symptoms indicates placenta previa?

1. Back pain 2. Abdominal pain 3. Painful vaginal bleeding *4. Painless vaginal bleeding* *Rationale:* The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Options 1, 2, and 3 are signs of abruptio placentae.

A nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse tells the client that she will:

1. Be placed in a supine position 2. Feel some pain during the procedure *3. Feel some pressure when the vaginal probe is moved* 4. Need to drink 2 quarts of water to attain a full bladder *Rationale:* Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound exam is well tolerated by most clients because it alleviates the need for a full bladder. The client is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

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:

1. Between 4 and 8 weeks' gestation 2. Between 6 and 10 weeks' gestation 3. Between 10 and 14 weeks' gestation *4. Between 16 and 20 weeks' gestation* *Rationale:* Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks of gestation the expectant mother first notices subtle fetal movements that gradually increase in intensity.

A pregnant client asks a nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following?

1. Bicycling with the legs in the air *2. Swimming* 3. Scuba diving 4. Low-weight gymnastics *Rationale:* Non-weight-bearing exercises are preferable to weight-bearing exercises. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non-weight-bearing exercise such as swimming is allowable.

A nursing student is asked to identify the location of the isthmus of the uterus. The student correctly states that the isthmus is the:

1. Body of the uterus 2. Uppermost part of the uterus 3. Tubular neck of the lower uterus *4. Area between the corpus of the uterus and the cervix* *Rationale:* The uterus has three divisions: the corpus, isthmus, and cervix. The isthmus is located between the corpus of the uterus and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus. The cervix is the tubular "neck" of the lower uterus.

A nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy?

1. Calcium intake should be increased for the duration of the pregnancy. 2. Iron supplements should be taken throughout pregnancy. 3. The maternal diet significantly influences fetal growth and development. *4. Pregnancy greatly increases the risk of malnourishment for the mother.* *Rationale:* Although pregnancy poses some nutritional risk for the mother, the client is not at risk for becoming malnourished. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements routinely are encouraged. Good nutrition during pregnancy significantly and positively influences fetal growth and development.

A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. The nurse's initial action is to:

1. Call the health care provider. 2. Monitor fetal heart rate. 3. Transfer the client to the labor room. *4. Gently hold the presenting part upward.* *Rationale:* On inspection of the perineum, if it is noted that the cord is compressed (prolapsed) by the presenting part, the client is immediately placed into Trendelenburg's position, and the presenting part is gently held upward to relieve the cord compression. This position is maintained until the health care provider evaluates the client further. Options 1, 2, and 3 may be appropriate actions but are not the initial actions.

A client presents at her health care provider's office 10 weeks pregnant with her first pregnancy. Which of the following is a presumptive sign of pregnancy that the client might be expected to have?

1. Chadwick's sign 2. Breast changes 3. Pigmentation changes of the face 4. A bluish discoloration of the vagina and cervix *Rationale:* Breast changes are a presumptive sign of pregnancy. A bluish discoloration of the vagina and cervix (Chadwick's sign) is a probable sign. Pigmentation changes of the face are not a sign of pregnancy, although they may occur with pregnancy.

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines that the client's primary physiological need at this time is:

1. Change in position 2. Intravenous analgesia 3. Oral food and fluids *4. Rest between contractions* *Rationale:* The birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy and facilitates voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which improves fetal tolerance of the stress of labor. No data in the question indicate that option 1 is necessary. Option 2 is incorrect because this action would likely cause central nervous system depression in the infant. Option 3 is incorrect because food and fluids are likely withheld at this time, except for ice chips.

A nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which of the following at this time?

1. Change the woman to a side-lying position. 2. Administer oxygen at 8 to 10 L/min by face mask. 3. Notify the registered nurse of a possible prolapsed cord. *4. Notify the registered nurse of a possible maternal infection.* *Rationale:* Signs of maternal infection include foul-smelling amniotic fluid, a maternal temperature in the presence of adequate hydration (adequate urine output), and fetal tachycardia. The nurse should inform the registered nurse of these data (who will then notify the health care provider) so that treatment can be initiated. Options 1, 2, and 3 are unrelated to the data in the question.

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, the nurse should first:

1. Check for pedal edema. 2. Assess the dorsalis pedis pulses. *3. Check for signs of thrombophlebitis.* 4. Tell the client to apply heat to the affected area when cramps occur. *Rationale:* Leg cramps may be a result of compression of the nerves supplying the legs because of the enlarging uterus, a reduced level of diffusible serum calcium, an increase in serum phosphorus, or the presence of thrombophlebitis. In the pregnant client who complains of leg cramps, the nurse would first check for signs of thrombophlebitis and notify the registered nurse. If thrombophlebitis is not present, the nurse may be instructed to massage and place heat on the affected area, dorsiflex the foot until the spasm relaxes, or have the client stand on a cold surface. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level. Although the nurse may check for edema and assess the pedal pulses, these would not be the first actions.

A nurse is providing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse would instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?

1. Cheese 2. Spinach *3. Dried fruits* 4. Orange juice *Rationale:* The best source of calcium is dairy products. Women with lactose intolerance need other sources of calcium because they are not able to consume dairy products. Calcium is present in dark green leafy vegetables, broccoli, legumes, nuts, and dried fruits. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. Orange juice does not contain significant amounts of calcium unless fortified with calcium. Option 1 is a dairy product and cannot be eaten by a client who has lactose intolerance.

A nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which of the following at the client's bedside?

1. Code cart 2. Suction machine *3. Intravenous (IV) supplies* 4. Nasogastric tube *Rationale:* The client who is a gravida VI is at risk for possible uterine atony. An IV access is needed so that blood and medication can be administered if necessary. Options 1, 2, and 4 are unnecessary items.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is to:

1. Complete routine newborn care measures quickly. *2. Determine the parents' desires for contact with the newborn.* 3. Encourage immediate breast-feeding. 4. Suggest the mother hold the newborn after the placenta is delivered. *Rationale:* Although immediate contact may be important for attachment or breast-feeding, the parents' wishes concerning contact with their newborn must be supported and determined first. The remaining options would follow the initial intervention.

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 that it:

1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria *3. Connects the umbilical vein to the inferior vena cava* 4. Connects the umbilical artery to the inferior vena cava *Rationale:* The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

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?

1. Contact the health care provider. 2. Instruct the client to maintain bedrest for the remainder of the pregnancy. *3. Tell the client that these are common and they may occur throughout the pregnancy.* 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition. *Rationale:* Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions.

A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by:

1. Contracting and then consciously relaxing different muscle groups 2. Contracting an area of the body such as an arm or leg and then concentrating on letting tension go from the rest of the body *3. Massaging the abdomen during contractions using both hands in a circular motion* 4. Instructing the significant other to stroke or massage a tightened muscle by the use of touch *Rationale:* Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure the woman contracts an area such as an arm or leg then concentrates on letting tension goes from the rest of the body. Touch relaxation helps the women to learn to loosen taut muscles when they are touched by her partner.

A nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by:

1. Contracting and then consciously relaxing different muscle groups 2. Contracting an area of the body such as an arm or leg and then concentrating on letting tension go from the rest of the body *3. Massaging the abdomen during contractions using both hands in a circular motion* 4. Instructing the significant other to stroke or massage a tightened muscle by the use of touch *Rationale:* Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg then concentrates on letting tension go from the rest of her body. Touch relaxation helps the woman to learn to loosen taut muscles when she is touched by her partner.

A client delivers a viable male neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be:

1. Critical 2. Poor 3. Fair *4. Good* *Rationale:* The APGAR scoring system was designed to evaluate the physical condition of the newborn at birth and determine the immediate need for resuscitation. Scores range from 0 to 10. A score of 8 to 10 indicates a newborn in good condition.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta:

1. Cushions and protects the fetus 2. Maintains the body temperature of the fetus 3. Surrounds the fetus and allows for fetal movement *4. Provides an exchange of nutrients and waste products between the mother and the fetus* *Rationale:* The placenta provides an exchange of nutrients and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and allows for fetal movement. The amniotic fluid also maintains the body temperature of the fetus.

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted?

1. Decreased fetal heart rate variability 2. Presence of late decelerations *3. Presence of accelerations* 4. Evidence of fetal bradycardia *Rationale:* Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system. Decreased variability, late decelerations, and bradycardia are representative of decreased oxygenation of the fetus.

A nurse is assigned to care for a nulliparous client who is having a precipitate delivery. The nurse reports which maternal focused observations?

1. Descent of 1 cm per hour 2. Latent phase of 2 hours *3. Decreased periods of uterine relaxation between contractions* 4. Dilation of the cervix of 2 to 4 cm per hour during the active phase *Rationale:* Inadequate relaxation between contractions could interfere with the transfer of oxygen and nutrients to the fetus through the placenta. All other options are within normal limits for a nulliparous woman and do not require reporting.

A nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as the effective teaching method?

1. Describe the process verbally in great detail. 2. Place a monitor on the client's abdomen, and use it as a visual. *3. Palpate for uterine contractions at the same time as the client.* 4. Provide a pamphlet with both multiple pictures and drawings. *Rationale:* Option 3 is correct because it most fully uses teaching and learning principles. It provides for verification of whether the client can perform the skill, and gives immediate feedback about the client's level of understanding. A verbal description may be useful but does not provide for verification that the skill has been learned. Application of a fetal monitor is unnecessary and is more costly and time-consuming. Providing written material is incorrect because providing written material does not guarantee that the client has learned the skill.

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which of the following data would best alert the nurse to early signs of hypovolemic shock?

1. Diminished peripheral pulses 2. Decreased blood pressure 3. Cold and clammy skin *4. Restlessness and agitation* *Rationale:* Early signs of hypovolemic shock include restlessness, anxiety, and agitation. Later signs of hypovolemic shock include a falling blood pressure, diminished peripheral pulses, pallor, cold and clammy skin, and urine output less than 30 mL/hr. Options 1, 2, and 3 are all signs of late hypovolemic shock. Option 4 is the correct option.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and tells the partner to:

1. Dorsiflex the client's foot while flexing the knee. 2.Plantarflex the client's foot while flexing the knee. *3. Dorsiflex the client's foot while extending the knee.* 4. Plantarflex the client's foot while extending the knee. *Rationale:* Leg cramps often occur when the pregnant woman stretches her leg and plantarflexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. Therefore, the remaining options are incorrect.

A nurse is providing instructions to a pregnant woman regarding measures that will strengthen the perineal floor muscles. The nurse instructs the client to:

1. Drink 8 ounces of fluid six times per day. 2. Wipe the perineal area anterior to posterior after toileting. *3. Perform Kegel exercises in 10 repetitions, three times per day.* 4. Perform pelvic tilt exercises in 10 repetitions, three times per day. *Rationale:* Kegel exercises strengthen the pelvic floor. Option 1 relates to hydration that is important for normal physiological body functioning. Option 2 will help prevent urinary tract infections. Pelvic tilt exercises will reduce backache.

A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation?

1. Drinking six to eight glasses of water daily 2. Daily activity such as walking or swimming 3. Increasing whole grains and fresh vegetables in the diet *4. Adding 1 tablespoon of mineral oil to a bowl of cereal daily* *Rationale:* Mineral oil should not be used as a stool softener because it inhibits the absorption of fat-soluble vitamins in the body. Constipation should be treated with increased fluids (six to eight glasses per day) and a diet high in fiber. Increasing exercise is also an excellent way to improve gastric motility.

A perinatal client is at risk for toxoplasmosis. The nurse should teach the client which of the following to prevent exposure to this disease?

1. Eat raw meats. 2. Wash hands only before meals. *3. Avoid exposure to litter boxes used by cats.* 4. Use topical corticosteroid treatments prophylactically. *Rationale:* Infected house cats transmit toxoplasmosis through feces. Handling litter boxes can transmit the disease to the maternity client. Meats that are undercooked can harbor microorganisms that can cause infection. Hands should be washed throughout the day when items that could be contaminated are handled. Topical corticosteroid treatment is not the pharmacological treatment of choice for toxoplasmosis.

A client who is 8 weeks pregnant calls the clinic and speaks to the nurse about complaints of nausea and vomiting every morning. To promote relief, the nurse suggests:

1. Eating a high-fat diet 2. Increasing fluids with meals *3. Eating crackers before arising* 4. Eating three large meals per day *Rationale:* Some measures for decreasing morning nausea are keeping crackers, melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats in the diet; and consuming adequate fluid between meals, but not with meals.

A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information?

1. Effects of diabetes on the pregnancy and fetus 2. Nutritional requirements for pregnancy and diabetic control *3. To avoid exercise because of the negative effects on insulin production* 4. To be aware of any infections and report signs of infection immediately to the health care provider *Rationale:* Options 1, 2, and 4 are important points to include in the teaching plan for the new diabetic client. Exercise is necessary for a pregnant diabetic woman. Concepts related to the timing of exercise, control of food intake, and insulin around the time of exercise should be included in the plan.

The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to:

1. Eliminate between-meal snacks. *2. Drink decaffeinated coffee and tea.* 3. Lie down for 30 minutes after eating. 4. Substitute salt in cooking for other spices. *Rationale:* Spices tend to trigger heartburn. Caffeine, like spices, may cause heartburn and needs to be avoided. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.

A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of:

1. Emotional immaturity 2. An undiagnosed psychiatric disorder *3. Acute anxiety and the need for support* 4. A stubborn personality *Rationale:* Any of the situations identified in the options may contribute to the reason for the client's behavior, but the most likely reason is anxiety. Option 3 is the only option that supports the information identified in the question. The client may be anxious about the unknown effects of complications, and the presence of a support person while dealing with a crisis is crucial. There are no data in the question to support options 1, 2, and 4.

A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client?

1. Fatigue 2. Drowsiness *3. Uterine hyperstimulation* 4. Early decelerations of the fetal heart rate *Rationale:* Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Fatigue and drowsiness may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

A nurse is providing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which of the following in the discussion?

1. Emphasizing the need to eliminate snack foods 2. Encouraging the need to avoid eating at local fast-food restaurants 3. Encouraging the adolescents to eat when hungry rather than three times a day *4. Describing the appropriate amount of weight gain required during the pregnancy* *Rationale:* The developmental stage of the adolescent needs to be addressed when the nurse is providing instructions regarding nutrition during pregnancy. The adolescent should not be told to eliminate favorite foods and places to eat. This may cause the adolescent to rebel. Eating only when hungry could lead to a deficit in nutrients. The adolescent is more likely to follow suggestions when the nurse explains why the weight gain is important.

A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client's feelings of anxiety by:

1. Emphasizing the technical aspects of this type of delivery 2. Deciding how soon the client should see the baby after delivery 3. Decreasing the partner's anxiety by keeping him or her in the waiting area *4. Encouraging the client to discuss her concerns and desires regarding anesthesia options* *Rationale:* Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse, which do not involve client input. A woman undergoing cesarean delivery often feels disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help to alleviate these feelings. Too much technical information may increase the client's anxiety. The presence of a support person is helpful.

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which of the following nursing actions is appropriate?

1. Encourage the client's coach to continue encouraging breathing techniques. 2. Encourage the client to continue pushing with each contraction. 3. Continue monitoring the fetal heart rate. *4. Notify the registered nurse (RN).* *Rationale:* A normal fetal heart rate is 120 to 160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the RN needs to be notified. Options 1, 2, and 3 are not appropriate nursing actions in this situation.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened?

1. Encourage the mother to breast-feed soon after birth. *2. Support the mother in her reaction to the newborn infant.* 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction in the birth record. *Rationale:* Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the mother's feelings.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:

1. Estimate the fetal size. 2. Check pelvic adequacy. 3. Administer an analgesic. *4. Determine the maternal and fetal vital signs.* *Rationale:* To evaluate a woman's physical well-being, her temperature, pulse, respirations, and blood pressure (as well as the fetal heartbeat) are checked. Option 3 is incorrect, because it would be too premature for an analgesic; medication given too early tends to slow or stop labor contractions. Options 1 and 2 are incorrect. These assessments should be performed by the health care provider during prenatal visits.

A client calls the health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which of the following in the urine?

1. Estrogen 2. Progesterone *3. Human chorionic gonadotropin (hCG)* 4. Follicle-stimulating hormone (FSH) *Rationale:* In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests. Options 1, 2, and 4 are incorrect.

A nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as:

1. Exhaustion *2. Fear of losing control* 3. Involuntary grunting 4. Valsalva's maneuver *Rationale:* Pains, helplessness, and fear of losing control are possible client responses in the transition stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, and low-pitched grunting sounds usually indicate a woman is working effectively with contractions.

A nurse is assisting a client who, at 38 weeks of gestation reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. What is the first nursing action?

1. Explain the reason for these symptoms. 2. Place a cool washcloth on the client's forehead. 3. Measure blood pressure, pulse, and respirations. *4. Place a wedge pillow under the client's right side.* *Rationale:* The symptoms suggest supine hypotension caused by compression of the aorta and inferior vena cava by the gravid uterus. Compression of these vessels is relieved by the placement of a wedge pillow under the woman's right side. Although the actions in the other options may be implemented, they are not the first action because they will not eliminate the problem.

A nurse is assigned to care for a client experiencing dystocia. In planning care, the nurse would consider the highest priority to be frequent:

1. Explanations to family members about what is happening in this situation 2. Comfort measures, change of position, and touch 3. Reinforcement of breathing techniques learned in childbirth preparatory classes *4. Monitoring for changes in the physical and emotional condition of the mother and fetus* *Rationale:* All the options are correct and would be implemented during the care of the client. However, the highest priority is to monitor for changes in physiological integrity in both the mother and the fetus.

A client who is 6 months pregnant is attending her first prenatal visit. On the first prenatal visit, the nurse notes that the client is gravida IV, para 0, aborta III. The client is 5 feet, 6 inches tall, weighs 130 pounds, and is 25 years old. She states, "I get really tired after working all day and can't keep up with my housework." Which factor in the above data would lead the nurse to suspect gestational diabetes?

1. Fatigue 2. Obesity 3. Maternal age *4. Fetal demise* *Rationale:* A previous history of unexplained stillbirths or miscarriages puts the client at high risk for gestational diabetes. Fatigue is a normal occurrence during pregnancy. A client at 5 feet, 6 inches tall, 130 pounds does not meet the criteria of 20% over ideal weight; therefore the client is not obese. To be at high risk for gestational diabetes, the maternal age should be greater than 30 years.

A nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:

1. Flat and nonfavorable for a vaginal birth 2. Rounded and favorable for a vaginal birth 3. Narrow, oval, and nonfavorable for a vaginal birth *4. Wedge-shaped, narrow, and nonfavorable for a vaginal birth* *Rationale:* The android pelvis is wedge-shaped and narrow and is nonfavorable for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable shape for a vaginal birth. An anthropoid pelvis is long, narrow, and oval. It is not as favorable of a shape for a vaginal birth as the gynecoid pelvis; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvis is flattened with a wide, short, oval shape and is also a nonfavorable shape for a vaginal birth.

The nurse is collecting data during the admission assessment of 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 would document the GTPAL for this client as:

1. G = 3, T = 2, P = 0, A = 0, L = 1 *2. G = 2, T = 1, P = 0, A = 0, L = 1* 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1 *Rationale:* Pregnancy outcomes can be described with the GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs:

1. General anesthesia 2. To be left totally alone 3. To push with her contractions *4. To regain her breathing pattern* *Rationale:* When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated. The client may be terrified of being left alone during this phase of labor.

A nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record would support this diagnosis?

1. Gestational diabetes *2. Maternal hypertension* 3. Hyperemesis gravidarum 4. Previous cesarean section *Rationale:* It is possible that placental abruption can result from maternal hypertension, which causes degenerative changes in the small arteries that supply intervillous spaces. This results in thrombosis, causing a retroplacental hematoma and leading to placental separation. Options 1, 3, and 4 are not specific risk factors for placental abruption.

A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?

1. Give acetaminophen (Tylenol) for the temperature. *2. Report the time of last food intake to the health care provider.* 3. Continue to time the contractions. 4. Determine the need for education. *Rationale:* The nurse should report the time of last food intake to the health care provider because general anesthesia is sometimes used for an emergency birth. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Providing acetaminophen is incorrect because it requires a health care provider's prescription. The remaining options are correct nursing actions but are a lesser priority.

The nurse is collecting data during the admission assessment of 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 would document which gravida and para status on this client?

1. Gravida I, para I *2. Gravida II, para I* 3. Gravida II, para II 4. Gravida III, para II *Rationale:* Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants. Options 1, 3, and 4 are incorrect on the basis of these definitions.

A client in the prenatal clinic presents with a blood pressure reading of 134/90 mm Hg, which is an elevation from last month's reading of 104/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?

1. Headaches 2. Generalized edema 3. Weight gain of 10 pounds *4. Trace amount of protein* *Rationale:* Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg; proteinuria is no more than 500 mg/day (trace to 1+), and symptoms such as headache, visual disturbances, or abdominal pain are absent. Therefore the only sign of mild preeclampsia from the options given is a trace amount of protein. A rapid weight gain and generalized edema may occur. Headaches are present in severe preeclampsia.

A nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse determines that the hormone responsible for the development of this sign is which of the following?

1. Human chorionic gonadotropin *2. Estrogen* 3. Progesterone 4. Prolactin *Rationale:* The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy.

A nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that its primary purpose is to:

1. Help prevent the possibility of developing a bladder infection. *2. Reduce the risk of injuring the bladder during the surgery.* 3. Achieve an accurate measurement of urinary output. 4. Assist the baby in engaging into the birth canal. *Rationale:* A urinary catheter is inserted preoperatively to keep the bladder empty to reduce the risk of injury to the bladder when the surgical incision is made. The presence of such an intervention is a common cause of bladder infection. Although the catheter does facilitate measurement of urinary output, that is not a critical matter for this client. The catheter would not assist the downward movement of the fetus.

A nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to:

1. Help the mother prepare for labor and delivery. *2. Reduce excessive maternal stress and fatigue.* 3. Prepare the 18-month-old child for maternal separation during hospitalization. 4. Avoid exposure to potential pathogens and resulting infections. *Rationale:* A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. Use of appropriate resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Options 1, 3, and 4 are not primary purposes for use of resources with the pregnant cardiac client.

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which of the following laboratory results indicates a physiological consequence of a result of this practice?

1. Hematocrit 37% *2. Hemoglobin 9.1 g/dL* 3. Glucose 86 mg/dL 4. White blood cell count 12,400/mm3 *Rationale:* Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin. The other three laboratory values are within normal limits for the pregnant woman.

A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

1. Hemoglobin of 11.5 g/dL *2. White blood cell count of 35,000 mm3* 3. Fetal heart rate of 154 beats per minute 4. Maternal pulse rate of 90 beats per minute *Rationale:* White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 mm3 to 15,000 mm3 up to 18,000 mm3. A count of 35,000 mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of hemodilution caused by an increase in plasma volume during pregnancy. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. A normal fetal heart rate is 120 to 160 beats per minute.

A nurse is assigned to assist in caring for a client in labor. The nurse would determine that which of the following would least likely indicate dystocia?

1. High level of maternal fear or anxiety 2. Failure of a fetus to descend *3. Progressive changes in the cervix* 4. Signs of fetal distress *Rationale:* Progressive changes in the cervix are a reassuring pattern in labor. Abnormal labor patterns are assessed according to the nature of the cervical dilation and fetal descent. Options 1, 2, and 4 could indicate signs of dystocia.

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which manifestation of this complication?

1. High platelet count *2. Oozing from injection sites* 3. A reddened rash over the trunk 4. Pain and swelling of the calf of one leg *Rationale:* DIC is a state of diffuse clotting in which clotting factors are consumed, which then leads to widespread bleeding. The client in DIC shows oozing from injection sites, petechiae, hematuria, and possibly other signs of bleeding. Platelets are decreased because they are consumed by the process; coagulation studies are prolonged because of a decreased ability to form clots. Pain and swelling of the calf is incorrect because it describes deep vein thrombosis. DIC is a widespread coagulopathy throughout the microvasculature, not isolated in one blood vessel. A red rash is not associated with this condition.

A nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?

1. High-Fowler's 2. Upright *3. With the hips elevated* 4. Semi-Fowler's *Rationale:* When cord compression is suspected, the woman is immediately repositioned. The client may be turned from side to side or the hips elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hand-and-knees position may also reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves. Options 1, 2, and 4 are inappropriate positions and may cause further cord compression.

A nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?

1. How to test for proteinuria 2. How to check for and manage preterm bleeding 3. How to manage the discomfort of early labor *4. How to check for signs of hypoglycemia and the required treatment* *Rationale:* In diabetes mellitus, the pancreas does not produce enough insulin for necessary carbohydrate metabolism. The physiological changes of pregnancy drastically alter insulin requirements. Pregnant diabetic clients should be taught to monitor themselves for hypoglycemia to minimize potential maternal and fetal effects that result from hypoglycemia. Testing for proteinuria is important for the mother with gestational hypertension. Management of preterm bleeding is taught to the mother with placenta previa. Managing the discomforts of early labor is important for all pregnant women.

A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. The nurse analyzes this data as indicative of:

1. Increased intracranial pressure 2. Dehydration 3. Decreased intracranial pressure *4. A normal finding* *Rationale:* The anterior fontanel is normally 2.5 to 5 cm in width and diamond shaped. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.

A nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which of the following?

1. Human chorionic gonadotropin (hCG) *2. Estrogen* 3. Progesterone 4. Prolactin *Rationale:* The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish tinge that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy.

A nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status to detect complications caused by:

1. Hypertrophy and increased contractility *2. The increase in circulating volume* 3. Fetal cardiomegaly 4. Rh incompatibility *Rationale:* Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase. This is especially important to monitor in the client whose heart may not tolerate this normal increase. Hypertrophy may result in cardiac disease, but the outcome would be a decrease in contractility, not an increase. Options 3 and 4 are related to the fetus, not the prenatal client.

For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes, lasting 60 to 70 seconds, and strong to palpation. She is 2 cm dilated and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?

1. Hypotonic 2. Precipitate *3. Hypertonic* 4. Protracted active phase *Rationale:* The client is 2 cm dilated and in the latent phase of labor. The most common type of dysfunctional labor at this point is hypertonic. A normal pattern during the latent phase of labor is contractions every 5 to 10 minutes, lasting 30 to 45 seconds, and mild in intensity. Precipitate labor is that which lasts in its entirety for 3 hours or less. The client already has been in labor for at least 4 hours. Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor.

A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include:

1. Hypotonic contractions *2. Shoulder dystocia* 3. Primigravidity 4. Weak bearing-down efforts *Rationale:* Shoulder dystocia at delivery causes increased pressure in the thin lower uterine segment and subsequently the risk for spontaneous rupture. Statistically, rupture is more common in multigravidas, especially when combined with the use of oxytocin. Hypotonic contractions and weak bearing-down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.

In providing initial care to the newborn following delivery, the priority action of the nurse is to:

1. Identify gestational age. 2. Identify the infant and mother. *3. Turn the infant's head to the side.* 4. Record the number of umbilical vessels. *Rationale:* The priority is to maintain an open airway. Turning the infant's head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.

If a precipitate delivery is imminent, which of the following would be the appropriate nursing action?

1. Immediately contact the health care provider, and call for assistance. 2. Medicate the mother, and delay the delivery until the health care provider arrives. *3. Put on sterile gloves, and gently guide the baby's head and shoulders out.* 4. Place the client in the Trendelenburg's position, and apply oxygen to the mother. *Rationale:* The baby is the priority. In an emergency situation, the nurse assists the client in the delivery by donning sterile gloves and gently guiding the head and the shoulder of the baby. There is rarely time to notify the health care provider. Options 2 and 4 are inappropriate and could cause distress to the fetus.

A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which of the following, if identified by the student, indicates an understanding of this process?

1. In the ovary *2. Fallopian tube* 3. Fundus of the uterus 4. In the corpus of the uterus *Rationale:* Fallopian tubes, also called oviducts, are 8 to 14 cm long and are quite narrow. The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube. Options 1, 3, and 4 are incorrect.

A maternity nurse is providing an inservice educational session to nursing students regarding the process of conception. The nurse determines that a nursing student understands this process if the student states that fertilization of a mature ovum occurs in which of the following areas?

1. In the uterus 2. In the ovary *3. In the distal third of the fallopian tube* 4. In the wall of the myometrium *Rationale:* The mature ovum is transported through the fallopian tube by the muscular action of the tube and the movement of the cilia within the tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovary. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovum. The other options are incorrect.

A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which of the following problems should receive highest priority?

1. Inability to perform activities 2. Expressing concern about appearance 3. Verbalizing fear about delivery *4. Dehydration* *Rationale:* For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, such as an interruption of blood flow to the respiratory system and placenta. Although options 1, 2, and 3 may be components of the plan of care at some point, fluid volume deficit is the priority.

A nurse in a prenatal clinic is teaching a group of pregnant clients about anemia. Which statement is accurate about the cause of physiological anemia of pregnancy or hemodilution?

1. Increased demand for iron 2. Decreased metabolism of iron *3. Increased blood volume of the mother* 4. Decreased maternal hemoglobin formation *Rationale:* During the latter part of the first trimester, the blood volume of the mother increases rapidly, more rapidly than blood cell production, leading to a decrease in the concentration of hemoglobin and erythrocytes. This is a normal process that causes a physiological anemia of pregnancy, or hemodilution. There is an increased metabolism of iron and maternal hemoglobin formation. The increased demand for iron is not a factor in the development of physiological anemia.

A nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?

1. Increasing the IV infusion rate 2. Keeping the client in the lithotomy position 3. Adding oxytocin (Pitocin) to the intravenous (IV) infusion *4. Putting the baby to the mother's breast and letting the baby suck* *Rationale:* Nipple stimulation causes the posterior pituitary of the woman to secrete natural oxytocin, which causes the uterine muscles to contract. This is a method that can be an independent action of the nurse. Options 1 and 3 are not appropriate and require a health care provider's prescription. Option 2 will not assist in the contraction of the uterus.

A nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination will not be performed on the client primarily because it could do which of the following?

1. Initiate premature labor *2. Cause profound hemorrhage* 3. Rupture the fetal membranes 4. Increase the chance of infection *Rationale:* Because the placenta is implanted low in the uterus, cervical examination could cause the disruption of the placenta and initiate profound hemorrhage. The other options are also correct, but the profound hemorrhage is of the greatest concern in this case.

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?

1. Initiating premature labor *2. Initiating severe hemorrhage* 3. Causing rupture of the fetal membranes 4. Increasing the chance of uterine infection *Rationale:* The placenta is implanted low in the uterus with placenta previa, and cervical examination could cause the disruption of the placenta and initiate severe hemorrhage. The other options are also correct, but the greatest concern based on the information in the question is hemorrhage.

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, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate?

1. Instruct the client to maintain bedrest for the remainder of the pregnancy. *2. Instruct the client that these are common and may occur throughout the pregnancy.* 3. Contact the health care provider. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition. *Rationale:* Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some women during pregnancy, options 1, 3, and 4 are unnecessary and inaccurate.

A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage:

1. Is a form of biofeedback to enhance bearing-down efforts during delivery *2. Is light stroking of the abdomen to facilitate relaxation during labor* 3. Is the application of pressure to the sacrum to relieve a backache 4. Stimulates uterine activity by contracting a specific muscle group while other parts of the body rest *Rationale:* Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used prior to transition to promote relaxation and relieve mild to moderate pain. Options 1, 3, and 4 are incorrect descriptions.

The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment:

1. Is more irritating to the newborn's eyes than silver nitrate drops 2. Must be administered at room temperature to prevent side effects 3. Is staining to the infant's skin and must be wiped off immediately *4. Is effective in protecting the newborn from Neisseria gonorrhoeae and chlamydia* *Rationale:* Erythromycin is effective in protecting the newborn against N. gonorrhoeae and chlamydia. It is less irritating to the newborn's eyes than silver nitrate, does not stain, and may be administered at any safe temperature.

Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal?

1. It is clear and dark amber. 2. It is light green with no odor. 3. It is thick and white with a musky odor. *4. It is pale, straw-colored with flecks of vernix.* *Rationale:* Amniotic fluid is normally pale and straw-colored and may contain flecks of vernix caseosa. It should have a watery, not thick, consistency and no odor. Amber fluid suggests the presence of bilirubin, whereas greenish fluid may indicate the presence of meconium and suggests fetal distress.

A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?

1. It maintains the uterine lining for implantation. 2. It stimulates metabolism of glucose and converts the glucose to fat. 3. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. *4. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.* *Rationale:* Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

The nurse is teaching 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 of the following purposes of estrogen?

1. It maintains the uterine lining for implantation. 2. It stimulates the metabolism of glucose, and converts glucose to fat. 3. It prevents the involution of the corpus luteum, and maintains the production of progesterone until the placenta is formed. *4. It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.* *Rationale:* Estrogen stimulates uterine development to provide an environment for the fetus, and it stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

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, 2012. Using Nägele's rule, the nurse determines the estimated date of birth to be:

1. July 12, 2013 *2. July 27, 2013* 3. August 12, 2013 4. August 27, 2013 *Rationale:* The accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20, 2012. When you subtract 3 months, you get July 20, 2012. If you add 7 days, you get July 27, 2012. Add 1 year to this, and you get the estimated date of birth: July 27, 2013.

A nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

1. Keeping the significant other informed of the progress of the labor 2. Providing comfort measures *3. Monitoring fetal status* 4. Changing the client's position frequently *Rationale:* The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status is the priority.

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding would indicate a serious nutritional disorder of pregnancy?

1. Ketone bodies in urine are negative. *2. Weight compared to last visit is a loss of 2.3 pounds.* 3. Patellar reflex is 2+. 4. Chadwick's sign is positive. *Rationale:* Weight loss along with the symptoms described in the question could indicate hyperemesis gravidarum. Ketone bodies, if present, would indicate protein wasting. Patellar reflexes would be used during magnesium sulfate administration. Chadwick's sign may be an indicator of pregnancy.

A nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?

1. Knee-chest 2. Semi-recumbent 3. Lithotomy *4. Lateral Sims'* *Rationale:* The lateral Sims' position places less stress on the perineum and increases the space needed for delivery. Because the upper leg is supported, the perineum can be better visualized as well. In addition, the lateral Sims' reduces the pressure of the gravid uterus on the mother's great vessels, so the circulation to the fetus is enhanced. The remaining options do not meet the current needs and so are not the best positions.

The maternity nurse prepares the client for which of the following techniques commonly used to relieve shoulder dystocia?

1. Leopold's maneuver *2. McRoberts' maneuver* 3. Placing the client in the lithotomy position 4. Positioning the client laterally on her left side *Rationale:* The McRoberts' maneuver is used to relieve shoulder dystocia. It is described as the woman flexing her thighs sharply against her abdomen to straighten the pelvic curve. This procedure will assist the fetus to move past the pelvic curve of the woman. Leopold's maneuver is used to locate the position and presentation of the fetus. Options 3 and 4 are positions, not techniques, and will not assist in relieving shoulder dystocia.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is:

1. Leopold's maneuvers *2. A manual pelvic examination* 3. Hemoglobin and hematocrit evaluation 4. External electronic fetal heart rate monitoring *Rationale:* Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia. Options 1, 3, and 4 are procedures that would not place the client at further risk.

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will likely have:

1. Less pressure on her cervix *2. Increased efficiency of contractions* 3. Decreased number of contractions 4. The need for increased blood pressure (BP) monitoring *Rationale:* Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not create the need for increased monitoring of the BP.

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse recommends which measure to help relieve both discomforts?

1. Lie on the left side with the feet dorsiflexed. 2. Soak the feet in hot water after performing 10 pelvic tilt exercises. 3. Lie on the right side with the feet elevated on a pillow and a heating pad on the back. *4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.* *Rationale:* The position described in option 4 will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities. Although the other options may seem useful, options 2 and 3 identify heat, which should be prescribed by the health care provider (HCP). Option 1 will not relieve back pain and ankle edema.

A nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

1. Locate fetal heart tones. 2. Warm the sonogram gel. *3. Have the client empty her bladder.* 4. Have the client drink 8 ounces of water. *Rationale:* An empty bladder contributes to a woman's comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram (ultrasound). Often, Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.

A maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phase, if stated by the nursing student, indicates a need to further research this area?

1. Luteal phase 2. Ovulatory phase *3. Proliferative phase* 4. Preovulatory phase *Rationale:* The ovarian cycle consists of three phases: preovulatory, ovulatory, and luteal. The proliferative phase is a phase of the endometrial cycle.

A nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:

1. Lying down *2. In a sitting position* 3. On the right side 4. On the left side *Rationale:* Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. The blood pressure should be obtained in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 3, and 4 are incorrect, and these positions may cause physiological stress that will affect the blood pressure.

A nurse is collecting data from a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:

1. Lying down 2. On the left side 3. On the right side *4. In a sitting position* *Rationale:* Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 2, and 3 are incorrect, and these positions may cause physiological stress that will affect the blood pressure.

A client in labor asks the nurse why it is so important to void frequently during labor. The nurse responds, using knowledge that the important reason is to:

1. Maintain adequate pain control. 2. Ensure comfort and conserve energy. 3. Prevent fetal placental complications. *4. Ensure labor progress and prevent injury.* *Rationale:* Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor. The statements contained in the other options are incorrect.

A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse initially include in the plan of care?

1. Maintain complete bedrest, encourage fluids, and reduce stimuli. *2. Maintain complete bedrest, monitor IV fluid intake, and monitor the fetal heart rate.* 3. Maintain complete bedrest, assist with the vaginal exam, and restrict food and fluids. 4. Maintain complete bedrest, monitor intravenous (IV) fluid intake, and monitor for uterine contractions. *Rationale:* Initial nursing actions for care of a pregnant client with bleeding include maintaining complete bedrest (to reduce the chance for further bleeding), initiating and monitoring an IV (anticipating the need for fluid replacement), and monitoring the fetal heart rate (assessing the status of fetus). Food and fluid may or may not be restricted. Reducing stimuli is not a priority consideration. A vaginal exam is not appropriate because it may stimulate uterine contractions and increase bleeding.

An assessment of a woman at 32 weeks' gestation indicates moderate fetal distress. What is the nurse's priority intervention?

1. Maintain intravenous fluids at a keep-vein-open rate. 2. Elevate the head of the bed to a semi-Fowler's position. *3. Administer oxygen with a face mask at 7 to 10 L/min.* 4. Set up for an immediate emergency cesarean section delivery. *Rationale:* Administering oxygen will increase the amount of oxygen for transport to the fetus. This action is essential regardless of the cause of the distress. Although the remaining options may be needed at some point during the care of the client, they are not the priority.

A nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. The nurse tells the client that estrogen:

1. Maintains the uterine lining for implantation 2. Stimulates metabolism of glucose and converts the glucose to fat 3. Prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed *4. Stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation* *Rationale:* Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

A nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing:

1. Marginal placenta previa *2. Complete placenta previa* 3. Incompetent cervix 4. Abruptio placentae *Rationale:* Complete placenta previa completely covers the internal cervical os, whereas partial or marginal does not. The remaining options are not related to the condition defined in the item.

A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete rupture occurs?

1. Maternal bradycardia 2. Excessive vaginal bleeding *3. Decreasing blood pressure* 4. Increased uterine contractions *Rationale:* Complete uterine rupture results in massive blood loss; however, external bleeding may not be impressive because most of the blood is lost into the peritoneal cavity. Signs of shock as evidenced by a falling blood pressure, tachycardia, tachypnea, pallor, cool clammy skin, anxiety, and pain develop quickly. Uterine rupture results in contractions ceasing.

Following delivery, a client experiences subinvolution of the uterus. The nurse develops a plan of care, recalling that which of the following is the primary cause for this occurrence?

1. Maternal hypertension 2. Increased estrogen levels 3. Increased progesterone levels *4. Retained placental fragments* *Rationale:* Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. Options 1, 2, and 3 are incorrect.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:

1. Measures the height of the maternal fundus 2. Determines the "lie" and "attitude" of the fetus 3. Is a systematic method for palpating the fetus through the maternal back *4. Is a systematic method for palpating the fetus through the maternal abdominal wall* *Rationale:* Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 3 are incorrect.

A nurse is providing information about health care to a pregnant client who is positive for human immunodeficiency virus (HIV). The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to:

1. Minimize the possibility of preterm labor. 2. Reduce the risks of anemia during pregnancy. *3. Avoid further stress on the maternal immune system.* 4. Minimize the risk of premature rupture of the membranes. *Rationale:* The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Although options 1, 2, and 4 are goals of care, option 3 represents the primary management issue for the HIV-infected client.

A nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) HIV to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?

1. Minimize the possibility of preterm labor. 2. Reduce the risks of anemia during pregnancy. *3. Minimize the potential for developing infections.* 4. Minimize the risk of premature rupture of membranes. *Rationale:* The pregnant client with HIV needs to avoid practices that can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such practices may place both the mother and fetus at additional risk during the pregnancy. The remaining options are not as specific to the care of this client.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:

1. Monitor the maternal vital signs. *2. Notify the registered nurse (RN) immediately.* 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions. *Rationale:* Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse would immediately contact the RN, who would then contact the health care provider. Options 1, 3, and 4 will delay necessary and immediate interventions.

A nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:

1. Monitor the oxytocin (Pitocin) infusion closely. *2. Provide pain relief measures.* 3. Prepare the client for an amniotomy. 4. Promote ambulation every 30 minutes. *Rationale:* Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately:

1. Monitors the contraction pattern *2. Checks the fetal heart rate* 3. Notes the amount, color, and odor of the amniotic fluid 4. Prepares the client for immediate delivery *Rationale:* When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 1 and 3 may also be a component of care but are not the immediate actions. There are no data to indicate that option 4 is necessary at this time.

A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding?

1. Nausea 2. Heavy vaginal mucus *3. Increase in fundal height* 4. Early deceleration on the monitor *Rationale:* The signs of concealed bleeding include increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in the fetal heart rate, or decreasing baseline variability. Options 1, 2, and 4 are not signs of concealed bleeding.

A nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which finding would support potential further maternal compromise?

1. Needing a nap each afternoon to feel rested *2. Vaginal spotting twice since the last prenatal visit* 3. Daily intake of elemental iron 4. Daily intake of 6 to 8 glasses of water *Rationale:* A variety of factors can further complicate the potential maternal and fetal effects of iron deficiency anemias during pregnancy. Such factors include geographic location, socioeconomic status, daily nutrition and fluid intake, compliance with supplemental medication regimens, and blood loss during pregnancy. A history of vaginal spotting may compromise maternal hemoglobin levels even further during the antenatal period. Option 4 represents appropriate client behaviors during pregnancy to ensure adequate nutrition and fluid balance. Option 3 represents daily supplementation during pregnancy. Requiring an afternoon nap is not the usual during pregnancy.

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 this type of pelvis is:

1. Not favorable for labor 2. Not normally a female pelvis type 3. A wide pelvis with a short diameter *4. The most favorable for labor and birth* *Rationale:* A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. An android pelvis would not be favorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. The platypelloid pelvis has a wide transverse diameter, but the anteroposterior diameter is short, thus making the outlet inadequate.

A nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?

1. Notify the health care provider. *2. Document the temperature.* 3. Retake the temperature in 30 minutes. 4. Inform the client that the temperature is elevated and antibiotics may be required. *Rationale:* The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A temperature above this level suggests infection that might require medical management. Options 1, 3, and 4 are unnecessary.

The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?

1. Notify the registered nurse immediately about the progress of labor. 2. Report the FHR to the registered nurse. *3. Continue to monitor the client.* 4. Prepare for delivery. *Rationale:* The normal fetal heart rate is 120 to 160 beats per minute. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR.

A 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?

1. Oliguria 2. Gestational diabetes *3. Maternal hypertension* 4. Hyperemesis gravidarum *Rationale:* Maternal hypertension is a risk factor associated with placental abruption. This factor leads to degenerative changes in the small arteries that supply the intervillous spaces of the placenta. This results in thrombosis, causing retroplacental hematoma and leading to placental separation. Options 1, 2, and 4 are not associated risk factors.

A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed?

1. Oral intake of 15 mg of warfarin (Coumadin) daily 2. Intravenous infusion of heparin sodium 5000 units daily *3. Subcutaneous administration of heparin sodium 5000 units daily* 4. Subcutaneous administration of terbutaline *Rationale:* Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antepartum, intrapartum, and postpartum periods. Warfarin is contraindicated during pregnancy because it crosses the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not cross the placental barrier, is safe to use during pregnancy and would be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only.

A nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system. When a participant in the class asks where the follicle-stimulating hormone is produced, the nurse responds that it is produced in the:

1. Ovaries 2. Pancreas *3. Anterior pituitary gland* 4. Posterior pituitary gland *Rationale:* The follicle-stimulating hormone and luteinizing hormone are produced by the anterior pituitary gland. The ovaries are the endocrine glands that produce estrogen and progesterone. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions during birth. The pancreas produces insulin and other enzymes that aid in digestion.

A nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is:

1. Oxytocin *2. Prolactin* 3. Progesterone 4. Testosterone *Rationale:* Prolactin stimulates the secretion of milk, called "lactogenesis." Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which of the following client problems does the nurse identify as important at this time?

1. Pain associated with the infection 2. Altered tissue integrity 3. Urinary tract infection *4. Fear about the safety of the fetus* *Rationale:* The primary concern for this client is safety of her fetus, not herself. Therefore the priority problem at this time is option 4. Option 3 is the client's diagnosis. Pain and altered tissue integrity may be seen in clients experiencing urinary tract infections, but the question includes no data to support either of the options.

A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?

1. Pain level is "0" and experiences a period of rest from labor contractions. *2. Pain level is "4" while a progressive labor pattern continues.* 3. Pain level is "5" with increased amounts of bloody show. 4. Contractions are longer, stronger, and closer together. *Rationale:* Effective pain management during labor does not interrupt the labor process but does provide relaxation and moderate pain relief to the mother. The increased bloody show and intensity of the contractions are not measures of effective pain management.

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?

1. Pelvic exam 2. Chorionic villus sampling 3. Amniocentesis *4. Contraction stress test* *Rationale:* A client with painless vaginal bleeding is at risk for going into labor, and a contraction stress test is indicated. The concern is that if fetal oxygenation is only marginally adequate when the uterus is at rest, it may be decreased further during uterine contractions. Options 2 and 3 are not appropriate at this time. A pelvic examination is contraindicated when there is vaginal bleeding.

A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which of the following is appropriate to suggest to the client?

1. Perform Kegel exercises during the play. 2. Limit fluid intake to 500 mL on the day of the play. *3. Wear a perineal pad to the play.* 4. Have a friend videotape the play for her. *Rationale:* Kegel exercises are useful to promote long-term bladder tone but will not be effective with one day's use. Limiting fluid intake can be harmful. A videotape will not satisfy the client's need to be present at the play. Wearing a perineal pad will give the client the security that she needs. The client should be instructed to remove a damp pad as soon as possible to decrease the incidence of infection.

A pregnant woman visiting a health care clinic for the first prenatal visit hears the health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the preembryonic period is the:

1. Period of time before conception *2. First 2 weeks of fetal development following conception* 3. Fetal development period from the beginning of the third week through the eighth week after conception 4. Longest period of fetal development *Rationale:* The preembryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period. The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form.

A nurse is caring for a client in preterm labor when her membranes rupture. The initial nursing action is to:

1. Place the client in the Trendelenburg's position. 2. Notify the health care provider immediately. *3. Monitor the fetal heart rate.* 4. Administer oxygen. *Rationale:* When the membranes rupture, the fetus can drop down in the birth canal. This increases the chances of compressing the umbilical cord and compromising the oxygen flow to the fetus. The initial nursing action is to monitor the fetal heart rate. The Trendelenburg's position is used if the cord is compressed. The health care provider needs to be notified, and oxygen may be administered to the client, but the initial action is stated in option 3.

A nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. The student describes the procedure correctly if the student states to:

1. Place the hands in the pelvis to perform the thrusts. 2. Perform abdominal thrusts until the object is dislodged. 3. Perform left lateral abdominal thrusts until the object is dislodged. *4. Place a rolled blanket under the right abdominal flank and hip area.* *Rationale:* To relieve an airway obstruction on an unconscious woman in an advanced stage of pregnancy, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. Options 1, 2, and 3 are incorrect and can cause harm to the woman and the fetus.

A nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. The nurse understands that the first maneuver will assess for which of the following?

1. Placenta previa *2. Fetal engagement* 3. Fetal lie and presentation 4. Strength of uterine contractions *Rationale:* The first maneuver is to determine the contents of the fundus (either fetal head or breech) and thereby the fetal lie and presentation. The third maneuver can determine whether the fetus is engaged in the pelvis. Leopold's maneuvers should not be performed during a contraction. Placenta previa is diagnosed by ultrasonography, not by palpation.

A nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?

1. Placing the mother in a supine position 2. Documenting the findings and continuing to monitor the fetal patterns *3. Administering oxygen via face mask* 4. Increasing the rate of the intravenous (IV) oxytocin infusion *Rationale:* Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions caused by the oxytocin. Option 2 would delay necessary treatment.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to:

1. Prepare for an oxytocin infusion. *2. Keep the client in a side-lying position.* 3. Prepare the client for epidural anesthesia. 4. Encourage the client to start pushing with the contractions. *Rationale:* Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury.

At 5:00 AM a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 AM with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to:

1. Prepare the client for the induction of labor. *2. Prepare the client for a cesarean delivery.* 3. Turn the client on her right side. 4. Palpate the bladder for fullness. *Rationale:* An indication for a cesarean delivery is the failure of labor to progress and fetal distress. In this situation, the nurse will prepare the client for this procedure. Option 1 would not be indicated in this case because the client has been in labor for 13 hours and the FHR is beginning to decrease. Clients are not turned on their right side for therapeutic reasons. Placing the client on the left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. While keeping the bladder empty facilitates the fetus's descent, it should have only a moderate effect on the client's current situation.

A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. What is the appropriate nursing action?

1. Prepare to induce labor. 2. Turn the client to the left side. *3. Prepare the client for a cesarean delivery.* 4. Continue to monitor the fetal heart rate pattern. *Rationale:* Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need to perform a cesarean delivery. Inducing labor is not indicated, in this case, because the client has been in labor for 12 hours without progress and with the presence of fetal distress. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava and would be implemented with any client in labor. Monitoring the fetal heart rate pattern is also appropriate for any client in labor but is not the most appropriate nursing action in this situation.

A nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which of the following?

1. Presence of vaginal bleeding *2. Characteristics of contractions* 3. Signs of hyperglycemia 4. Presence of edema *Rationale:* Dystocia is a slowed labor process. A prolonged labor is a potential for fetal distress. The nurse would specifically monitor the characteristics of the contractions. Options 1, 3, and 4 are unrelated to this condition.

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is:

1. Prolactin *2. Oxytocin* 3. Progesterone 4. Testosterone *Rationale:* Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Prolactin stimulates the secretion of milk, called lactogenesis. Progesterone stimulates the secretions of the endometrial glands and causes the endometrial vessels to become dilated and tortuous in preparation for possible embryo implantation. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the:

1. Prone position 2. Semi-Fowler's position 3. Trendelenburg's position *4. Supine position with a wedge under the right hip* *Rationale:* Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides for the displacement of the uterus. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, thus decreasing respiratory capacity and oxygenation.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection?

1. Proteinuria of 3+ 2. Presence of deep tendon reflexes 3. Serum magnesium level of 6 mEq/L *4. Respirations of 10 breaths per minute* *Rationale:* Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

A nurse is planning interventions for counseling a maternal client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time would be which of the following?

1. Provide all information regarding the disease immediately. 2. Allow the client to be alone if she is crying. *3. Provide emotional support.* 4. Avoid the topic of the disease. *Rationale:* Probably the most important of all nursing functions is providing emotional support to the client and family. Option 1 overwhelms the client with information while the client is trying to cope with the news of the disease. Option 2 is only appropriate if the client requests to be alone if not requested, the nurse is abandoning the client in time of need. Option 4 is nontherapeutic. Supportive therapy allows the client to express feelings, explore alternatives, and make decisions in a safe, caring environment.

A nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which of the following nursing interventions would be least likely to assist in meeting her emotional needs?

1. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy 2. Using a caring and supportive approach when dealing with a pregnant woman 3. Offering praise and reinforcement for compliance with treatment therapies *4. Providing the mother with pamphlets and booklets to read about the pregnancy* *Rationale:* The woman's emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse also should discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Option 4 does not provide a nurse-client interaction.

A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs?

1. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy 2. Using a caring and supportive approach when dealing with the pregnant woman 3. Offering praise and reinforcement for compliance with treatment therapies *4. Providing the mother with pamphlets and booklets to read about the pregnancy* *Rationale:* The woman's emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse should also discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Option 4 will least likely assist in meeting the emotional needs of the woman.

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing?

1. Quickening 2. Braxton Hicks contractions 3. Consistent increase in fundal height *4. Fetal heart rate of 180 beats per minute* *Rationale:* The fetal heart rate depends on the gestational age. It is 160 to 170 beats per minute during the first trimester, and it slows with fetal growth to approximately 120 to 160 beats per minute. Options 1, 2, and 3 are normal expected findings.

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 he or she observes:

1. Rapid clotting times 2. Pain and swelling of the calf of one leg 3. Laboratory values that indicate increased platelets *4. Petechiae, oozing from injection sites, and hematuria* *Rationale:* DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which priority action to assist in preventing a crisis from occurring during labor?

1. Reassure the client. *2. Administer oxygen as prescribed throughout labor.* 3. Maintain strict asepsis. 4. Prevent bearing-down. *Rationale:* During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. An intervention to prevent sickle cell crisis during labor includes administering oxygen as needed. Options 1, 3, and 4 are accurate information but not for the situation described in the question.

A nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for:

1. Red vaginal discharge 2. Abdominal pain *3. Signs of shock* 4. Leg pain *Rationale:* The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock caused by bleeding in the abdomen. Options 1, 2, and 4 are not manifestations of a ruptured uterus

A nurse is reinforcing the positive effects of breathing and relaxation techniques to a pregnant, cardiac client who has an 18-month-old child. What is the primary outcome for these interventions?

1. Reducing maternal stress and fatigue 2. Helping the client prepare for labor and delivery 3. Avoiding stress-induced infectious disease processes *4. Preparing for maternal-child separation during hospitalization* *Rationale:* A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The strategies identified in this question would primarily reduce maternal stress and fatigue. Although the other options identify possible outcomes, they are not the primary purpose of these strategies.

A client who consumes alcohol frequently is in the first trimester of pregnancy. What is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?

1. Reducing the potential for fetal growth restriction in utero 2. Promoting the normal psychosocial adaptation of the mother to pregnancy 3. Minimizing the potential for placental abruptions during the intrapartum period *4. Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures* *Rationale:* The first trimester, "organogenesis," is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this crucial period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman.

A nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the health care provider any early signs of vaginal discharge or perineal tenderness. What is the primary expected outcome for this intervention?

1. Relieves anxiety for the pregnant client 2. Eliminates the need for further unnecessary screenings *3. Assists in identifying infections that may need to be treated* 4. Minimizes the financial cost of caring for an HIV-positive client *Rationale:* The HIV-positive client may be further at risk for superimposed infections during pregnancy. Among these include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. The remaining options are benefits that can be experienced when complications such as infections are identified early.

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which of the following does the nurse anticipate to be prescribed?

1. Repeating hepatitis screen 2. Retesting the mother in 1 week 3. Administration of antibiotics during pregnancy *4. Administration of immune globulin and vaccine in the infant soon after birth* *Rationale:* A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive immune globulin and a vaccine soon after birth. Options 1, 2, and 3 are incorrect actions or treatment measures.

A nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which of the following at this time?

1. Report the fetal heart rate immediately. 2. Prepare for imminent delivery of the fetus. 3. Report the contractions because they reflect a potential complication. *4. Continue monitoring the client because the data reflect acceptable progress.* *Rationale:* The normal fetal heart rate ranges from 120 to 160 beats per minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, or persistently decreased variability, and an irregular fetal heart rate. Based on the data in the question, the nurse should continue to monitor the client.

A nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which of the following actions will the nurse take before the procedure to ensure the maintenance of fetal safety during the procedure?

1. Require that the client empty her bladder. *2. Test the ultrasound equipment to ensure proper functioning.* 3. Teach the client the signs and symptoms of labor. 4. Prepare a local anesthetic to be used during the insertion of the spinal needle. *Rationale:* Before 20 weeks of gestation, it is recommended to perform an amniocentesis with the bladder full. This pushes the uterus upward for better visualization. After week 20, the bladder is emptied before the test to minimize the risk of puncturing it during the test. The client does need to be taught about the signs and symptoms of labor because this action does not ensure fetal safety. The local anesthetic makes the insertion of the needle less painful but does not protect the fetus. The use of ultrasound to guide the procedure has greatly decreased the risk of fetal and placental damage during the procedure.

A nurse is assigned to care for a client admitted with severe preeclampsia. What is the priority nursing intervention for this client?

1. Restricting food and fluids 2. Monitoring blood glucose levels 3. Maintaining the client in a supine position *4. Minimizing the client's exposure to external stimuli* *Rationale:* The client with severe preeclampsia is kept on complete bedrest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs. Food and fluid are not restricted unless prescribed by the care provider.

A nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat:

1. Rice *2. Beans* 3. Cheese 4. Chicken *Rationale:* Sources of folic acid include green, leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Cheese is high in calcium, and rice and chicken are good sources of iron.

A nurse is providing 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 of the following food items in the diet?

1. Rice 2. Cheese 3. Chicken *4. Green, leafy vegetables* *Rationale:* Sources of folic acid include green, leafy vegetables, whole grains, fruits, liver, dried peas, and beans. The foods listed in options 1, 2, and 3 are not sources of folic acid.

A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:

1. Rounded and most favorable for a vaginal birth 2. Narrow and oval and not the most favorable for a vaginal birth *3. Wedge-shaped and narrow and nonfavorable for a vaginal birth* 4. Flat and nonfavorable for a vaginal birth *Rationale:* The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is a nonfavorable shape for a vaginal birth.

A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is:

1. Rounded and most favorable for a vaginal birth 2. Narrow and oval and not the most favorable for a vaginal birth 3. Wedge-shaped and narrow and nonfavorable for a vaginal birth *4. Flat and nonfavorable for a vaginal birth* *Rationale:* The platypelloid pelvic shape is flattened with a wide, short oval shape and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth.

A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:

1. Schedule the counting periods in the morning when the fetal movement is highest. 2. Lie on the stomach when preparing to count the fetal movement. 3. Expect the baby to move at least 35 times in 3 hours. *4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.* *Rationale:* Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium sulfate therapy is effective if:

1. Scotomas are present. *2. Seizures do not occur.* 3. Ankle clonus is noted. 4. The blood pressure decreases. *Rationale:* For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Ankle clonus indicates hyperreflexia and may precede the onset of eclampsia.

A client asks a nurse to describe how her baby is developing. The nurse bases the response on the knowledge that every organ system in the fetus is present by the end of which gestational week?

1. Second *2. Eighth* 3. Eleventh 4. Twelfth *Rationale:* At the end of the eighth week, all organ systems and external structures are present. Therefore options 1, 3, and 4 are incorrect.

A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?

1. Septic *2. Inevitable* 3. Incomplete 4. Threatened *Rationale:* An inevitable abortion is a termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild abdominal cramping and cervical dilation is present. An incomplete abortion presents with heavy bleeding, severe cramping, cervical dilation, and passage of large clots. A threatened abortion presents with slight to moderate bleeding and intermittent cramping, but no dilation. A septic abortion presents with bleeding with odor, cervical dilation, and fever. Cramping may be present.

Which finding in the prenatal client supports the medical diagnosis of placental abruption?

1. Severe vomiting 2. Ruddy complexion *3. Tender, rigid abdomen* 4. Purulent vaginal discharge *Rationale:* Signs of placental abruption include tender, rigid abdomen, cramp-like pain that is moderate to severe, dark red vaginal bleeding, and maternal shock and fetal distress. The other options are not findings in placental abruption.

A 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?

1. She is 5 feet, 2 inches tall and weighs 175 pounds. *2. She has a history of chronic hypertension.* 3. There is a family history of type 1 diabetes mellitus. 4. Her previous two babies were delivered by cesarean section. *Rationale:* Known risk factors that increase the risk of developing gestational diabetes include obesity (more than 198 lb), chronic hypertension, family history of type 2 diabetes mellitus, previous birth of a large infant (more than 4000 g), and gestational diabetes in a previous pregnancy. Options 1, 3, and 4 are not risk factors.

A nurse is collecting data on a pregnant woman who is human immunodeficiency virus (HIV) positive during the 32nd gestational week. The nurse reviews the data and determines that which finding requires further follow up?

1. Slight lower extremity edema *2. Increased shortness of breath and bilateral rales* 3. Active fetal movement 4. Weight gain of 22 pounds *Rationale:* HIV infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The finding in option 2 can be indicative of an opportunistic infection and requires followup.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?

1. Soft abdomen on palpation *2. Uterine tenderness on palpation* 3. No complaints of abdominal pain 4. Lack of uterine irritability or tetanic contractions *Rationale:* Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

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?

1. Soft uterus *2. Abdominal pain* 3. Nontender uterus 4. Painless vaginal bleeding *Rationale:* Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and localized over one region of the uterus, or diffuse over the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

1. Squatting *2. Left lateral* 3. Tailor sitting 4. Semi-Fowler's *Rationale:* Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her left side. Options 1, 3, and 4 are incorrect because they would not prevent hypotension.

During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. This action will primarily:

1. Stimulate and accelerate the labor process. 2. Minimize the necessity of a cesarean delivery. *3. Assist in preventing dehydration and hypoxemia.* 4. Reduce the need for analgesic administration. *Rationale:* A variety of conditions, including dehydration, hypoxemia, infection, and exertion can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for both the mother and fetus during labor. Options 1, 2, and 4 are incorrect.

A nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:

1. Stimulate the labor process. 2. Avoid the necessity of a cesarean delivery. *3. Prevent dehydration and hypoxemia.* 4. Eliminate the need for analgesic administration. *Rationale:* A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

During the intrapartum period, a nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:

1. Stimulate the labor process. 2. Avoid the necessity of a cesarean delivery. *3. Prevent dehydration and hypoxemia.* 4. Eliminate the need for analgesic administration. *Rationale:* A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and administering oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

A client in preterm labor is placed on bedrest. The nurse assists the client to which of the following advantageous positions?

1. Supine on the back *2. Left lateral* 3. High-Fowler's 4. Prone *Rationale:* The left lateral position takes pressure off of the aorta and the inferior vena cava most effectively. This increases the blood supply to the uterus. The supine (on the back) position places pressure on the vena cava and could disrupt blood flow to the fetus. A high-Fowler's position could place excess pressure on the diaphragm. A prone position is incorrect and would affect contractions and the labor process and be very uncomfortable for the mother.

A pregnant client is seen in the health care clinic with reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion?

1. Switch to a high-carbohydrate diet. 2. Eat a high-protein snack at bedtime. *3. Consume dry crackers before getting out of bed.* 4. Increase fluids with both meals and with snacks. *Rationale:* Some strategies for decreasing morning sickness are keeping crackers, melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats; and consuming adequate fluid between meals.

A nurse is monitoring a client in labor whose membranes rupture spontaneously. The initial nursing action is to:

1. Take the client's blood pressure. 2. Provide peripads to the client. 3. Note the amount, color, and odor of the amniotic fluid. *4. Determine the fetal heart rate.* *Rationale:* When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 1 and 3 are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleansing and changing clothing and may provide peripads to the client, but determining the fetal heart rate is the initial action.

A pregnant client is a gravida III, para 0, abortus II. She is placed on bedrest at home because of preterm labor. The nurse provides information to the husband, knowing that which of the following will assist to promote family adaptation?

1. Teaching the husband to administer and titrate tocolytic agents 2. Teaching the husband to instruct the wife how to perform Kegel exercises *3. Teaching the husband to perform passive range of motion and provide back rubs for his wife* 4. Telling the husband that sexual intercourse has probably caused the preterm labor *Rationale:* Range-of-motion exercises will help maintain muscle tone during bedrest, and back rubs provide skin-to-skin contact and are comforting. The inclusion of the significant other promotes adaptation and decreases the sense of isolation. Option 4 will lead to guilt and maladaptation. The husband should not be expected to titrate medications. Kegel exercises are beneficial but will not provide the human-to-human contact that promotes family adaptation.

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection the client questions everything the nurse does and behaves in an anxious manner. The appropriate nursing response or action at this time would be to:

1. Tell her not to worry. 2. Ignore her unfounded concerns, and continue. *3. Explain the purpose of the nurse's actions, and answer all questions.* 4. Refer the client to a counselor. *Rationale:* For the prenatal cardiac client, stress should be reduced as much as possible. It is important to be certain the woman understands the purpose of any procedures so she does not worry unnecessarily. Options 1, 2, and 4 are nontherapeutic at this time. Explaining the purpose of nursing actions will assist in decreasing the stress level of the client.

A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse determines that:

1. The client has the herpes simplex virus. *2. HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.* 3. The newborn infant will have this disease at birth. 4. This client has contracted an airborne disease. *Rationale:* Diagnosis depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA test. Options 1 and 4 are incorrect because HIV occurs primarily through the exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk of developing this infection.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which of the following observations by the nurse indicates a need for teaching?

1. The client is wearing pantyhose. 2. The client is wearing nonslip shoes. *3. The client is wearing knee-high hose.* 4. The client is wearing shoes with arch supports. *Rationale:* Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing, such as knee-high hose, impedes venous return from the lower legs and thus places the client at higher risk for developing varicosities. Clients should be encouraged to wear support hose (pantyhose). Flat, nonslip shoes with proper support are important to help the pregnant woman maintain proper posture and balance and minimize fall risks.

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?

1. The client will not have sexual relations during the remainder of pregnancy. *2. The client will not develop an opportunistic infection during the remainder of pregnancy.* 3. The client is advised of an HIV support group. 4. The client is assisted with the grief process. *Rationale:* HIV is caused by a retrovirus that infects T lymphocytes. This disables the body's ability to fight infection. Nursing goals are directed at the prevention of infections. Sexual relations are not contraindicated with the proper use of protective devices. Options 3 and 4 are the focus of interventions, not goals.

A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?

1. The client will verbalize a reduction of pain. 2. The client will no longer have leg pain. 3. The client will report that an infection is likely to occur. *4. The client will be able to identify measures to prevent infection.* *Rationale:* The uterus is theoretically sterile during pregnancy until the membrane ruptures, after which it is capable of being invaded by pathogens. Puerperal infection is a major cause of maternal morbidity and mortality. Option 3 is inaccurate. Options 1 and 2 are not directly related to infection.

A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse provides instructions to the client regarding therapeutic management of tuberculosis and tells the client that:

1. The need for therapeutic abortion is required. 2. Medication will not be started until after delivery of the fetus. *3. Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.* 4. The newborn infant must receive medication therapy immediately following birth. *Rationale:* More than one medication may be used to prevent growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must continue for a prolonged time. The preferred treatment for the pregnant woman is daily isoniazid plus rifampin for a total of 9 months. Ethambutol is also added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 months on the infant, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid would be given.

A 38-week gestational pregnant woman arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing:

1. The passage of the mucous plug 2. Abruptio placentae 3. Rupture of the amniotic sac *4. Placenta previa* *Rationale:* The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucous plug appears pink or as blood-tinged mucus. A ruptured amniotic sac would include findings such as a watery vaginal drainage. Findings of abruptio placentae include dark red vaginal bleeding and abdominal pain.

A nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

1. The umbilical cord shortens in length and changes in color 2. A soft and boggy uterus 3. Maternal complaints of severe uterine cramping *4. Changes in the shape of the uterus* *Rationale:* Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness but not sudden uterine cramping.

A 15-year-old client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which of the following treatments for acne will likely be avoided with this client?

1. Topical erythromycin 2. Exfoliation 3. Cleansing with antibacterial soap *4. Oral tetracycline hydrochloride* *Rationale:* Tetracycline is avoided during pregnancy because it may cause discoloration of the child's teeth when they erupt. Options 1, 2, and 3 are acceptable measures to treat acne during pregnancy.

A nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. The nurse tells the client that:

1. Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. *3. A cesarean section will be necessary if vaginal lesions are present at the time of labor.* 4. Daily administration of acyclovir (Zovirax) is necessary during the first trimester of the pregnancy. *Rationale:* For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy and should be used only for a life-threatening infection. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, they should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry will promote healing.

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in the:

1. Trendelenburg's position with the legs in stirrups 2. Semi-Fowler's position with a pillow under the knees 3. Prone position with the legs separated and elevated *4. Supine position with a wedge under the right hip* *Rationale:* Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's, prone, or Trendelenburg's position with the legs in stirrups is not practical for this type of abdominal surgery.

A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid doing which of the following at this time to assist in relieving the back discomfort?

1. Turn the client to the lateral position. *2. Assist the client to ambulate in the room.* 3. Allow the client to sit on the side of the bed. 4. Place a pillow under one hip when lying in the supine position. *Rationale:* Ambulation should be avoided because the client is in active labor and received an analgesic 1 hour ago. Each of the other options identifies measures that are both safe and effective to reduce back discomfort for the client.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of:

1. Two umbilical veins and one umbilical artery *2. Two umbilical arteries and one umbilical vein* 3. Arteries that carry oxygenated blood to the fetus 4. Veins that carry deoxygenated blood to the fetus *Rationale:* Blood pumped by the fetus' heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus.

When examining the umbilical cord immediately after birth, the nurse expects to observe:

1. Two veins 2. One artery *3. Two arteries* 4. A musty odor *Rationale:* The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There should be no odor.

A nurse assists the nurse-midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (−) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity for the client?

1. Up in chair 2. Ambulation *3. Complete bedrest* 4. Bathroom privileges *Rationale:* Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions.

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving?

1. Urinary output has increased. 2. There is no evidence of dependent edema. *3. The client complains of a headache and blurred vision.* 4. The blood pressure reading has returned to the prenatal baseline. *Rationale:* Options 1, 2, and 4 are all signs that the GH is being resolved. Option 3 is a symptom of the worsening of the GH.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which of the following information would be of concern to the nurse?

1. Urinary output of 20 mL since the last check 2. Deep tendon reflexes of 2+ *3. Respirations of 10 breaths per minute* 4. Fetal heart tones of 116 beats per minute *Rationale:* Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication needs to be reassessed. Option 1 is adequate because there is 20 mL of urine in 30 minutes. The acceptable criterion is greater than 30 mL/hr. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus.

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse teaches the client about the signs that need to be reported to the health care provider (HCP) and tells the client to call the HCP if:

1. Urine output increases. 2. Fetal movements are more than four per hour. *3. Weight increases by more than 1 pound in a week.* 4. The blood pressure reading is between 122/80 and 138/88 mm Hg. *Rationale:* The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported.

A nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which of the following would be a part of the teaching plan for this class?

1. Use of over-the-counter medications 2. Fetotoxic substances in the workplace 3. Effects of secondary cigarette smoke on the fetus *4. Travel precautions and use of shoulder seat belts* *Rationale:* Placental separation as a result of uterine distortion can occur from trauma, such as in car accidents and decreases or shuts off uteroplacental circulation. Partial placental separation will also result in fetal distress, with the amount of distress depending on the degree of separation. Complete separation leads to sudden severe fetal distress followed by fetal death. Use of the shoulder seat belt decreases the risk of placental separation by preventing the traumatic flexion of the woman's body from sharp braking or impact, if an accident occurs. Although options 1, 2, and 3 are important teaching points, they are not related to physical trauma affecting the fetus.

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which of the following? *Select all that apply.*

1. Using the fetal lungs and liver to promote gas exchange *2. Carrying more oxygen on fetal hemoglobin than maternal hemoglobin* *3. Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output* *4. Bypassing the fetal lungs to circulate oxygen rich blood* *5. Using the fetus's beating heart to pump blood in the circulatory system* 6. Completely shutting off circulation to fetal lung tissue *Rationale:* The fetal lungs do not function for respiratory gas exchange, so a special circulatory pathway, the ductus arteriosus, bypasses the lungs. A small amount of blood circulates through the resistant lung tissue, but the majority follows the path with less resistance through the ductus arteriosus into the aorta. The following three special characteristics enable the fetus to obtain sufficient oxygen from maternal blood: fetal hemoglobin carries 20% to 30% more oxygen than maternal hemoglobin; the hemoglobin concentration of the fetus is about 50% greater than that of the mother; and the fetal heart rate is 110 to 160 beats per minute, making the cardiac output per unit of body weight higher than that of an adult.

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of:

1. Uterine atony 2. Placenta previa 3. Abruptio placentae *4. Placental separation* *Rationale:* As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The clinical manifestations identified in the question are not related to options 1, 2, and 3.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. *Select all that apply.*

1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain *4. Bright red vaginal bleeding* *5. Soft, relaxed, nontender uterus* *Rationale:* Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abruptio placentae, the abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

A nurse is teaching a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which of the following occurs?

1. Visual disturbances 2. Rapid weight gain 3. Facial edema *4. Irregular, painless contractions* *Rationale:* Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. What is the appropriate action to deliver the placenta?

1. Wait 5 minutes and then pull on the cord. *2. Pull gently on the cord as the mother bears down.* 3. Place traction on the cord and pull on the placenta as it enters the vaginal canal. 4. Encourage placental separation using forceps, and allow the placenta to deliver spontaneously. *Rationale:* After the placenta separates, it usually can be delivered if the mother bears down. The cord may be gently pulled to assist in the delivery of the placenta. Excess traction on the cord may cause it to break, making the placenta harder to deliver. The remaining options are incorrect actions.

Of the following, which would be the appropriate method to use to deliver the placenta after a precipitate delivery?

1. Wait for approximately 30 minutes and then pull it out. 2. Wrap the cord around a sponge stick and tug upward. *3. Gently guide the placenta out after a spontaneous separation.* 4. The nurse's scope of practice does not include delivering the placenta. *Rationale:* The placenta is allowed to separate spontaneously, and then it is very gently pulled or guided out. The placenta is attached to the uterine wall, and if it is pulled hard or left in the uterus, hemorrhage would occur. There may be times when it is necessary for a nurse to assist in the delivery of the placenta.

A nurse is preparing a client for an emergency cesarean delivery. Which of the following information regarding the client has priority?

1. Was the informed consent form signed? 2. Has a urinary catheter been inserted? *3. When was the last time the client ate or drank?* 4. Is there a current complete blood cell count result in the client's medical record? *Rationale:* The status of oral intake is the most important data to collect. This information will provide the basis for the type of anesthesia used to prevent aspiration during surgery and postoperatively. Options 1, 2, and 4 are all routine preoperative procedures.

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week?

1. Week 12 2. Week 18 *3. Week 28* 4. Week 32 *Rationale:* Surfactant, a substance needed to facilitate neonatal breathing, begins to be produced at approximately week 28. Therefore the remaining options are incorrect.

A pregnant client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the sex of the fetus can usually be determined by:

1. Weeks 6 to 8 2. Weeks 8 to 10 *3. Weeks 12 to 16* 4. Weeks 20 to 22 *Rationale:* By the end of the 12th week, the fetal sex can be determined by the appearance of the external genitalia on ultrasound.