Ch 11 SS Pregnancy Assessment
The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best?
"At 36 weeks' gestation, the fundus is in the normal expected location."
A nurse is educating a prenatal client at her second visit. The client is worried about "blotchy brown spots" on her forehead. The nurse reassures the client about this change by giving which appropriate response?
"Avoid sun because it will make the discoloring darker."
An obviously pregnant woman appears for her first prenatal visit. She reports a headache and generalized abdominal pain which has persisted over the past couple months. Which question should the nurse prioritize after determining the client is approximately 24 weeks' gestation, appears nervous, and is reluctant to have a full physical assessment?
"Do you feel safe at home?"
A nurse is educating a pregnant client about obtaining a blood sample for an alpha-fetoprotein (AFP) level. Which response by the client indicates that the health teaching was successful?
"If my AFP level is high, it could mean there is a problem with my baby's spinal cord."
A nurse is conducting a program for a group of woman about the importance of prenatal care. The nurse determines a need for further instruction based on which group statement?
"Prenatal care should begin at the first visit to the obstetrician."
A patient at 6 weeks' gestation asks if she can listen to the fetal heart sounds. The nurse informs the patient that fetal heart sounds cannot be heard with a Doppler until when?
10 to 12 weeks
The nurse assesses a 20-week gestational client at a routine prenatal visit. What will the nurse predict the fundal height to be on this client experiencing an uneventful pregnancy?
20 cm
Charlene McCoy, who has several children already, reports for a first prenatal visit. She seems preoccupied and withdrawn, and she makes consistently negative remarks about the pregnancy. Reviewing her records, you note that she is receiving a serotonin reuptake inhibitor. What should you do?
Alert the RN or primary care provider
What anatomic area should be examined when assessing Montgomery tubercles?
Breasts
A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply.
Establish a baseline of present health. Determine the gestational age of the fetus. Monitor for fetal development and maternal well-being. Identify women at risk for complications.
Following her first prenatal visit, a woman will be scheduled for a sonogram to confirm pregnancy length and document healthy fetal growth at 3 to 5 weeks of pregnancy.
False
Which information is most important in order to decrease the risk of complications if the client decides to work until her due date?
Frequent rest periods
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of a miscarriage within the first trimester. The nurse is correct to document the history as:
G = 3, T = 1, P = 0, A = 1, L = 1
A nurse is classifying the pregnancy history of a woman who has had five pregnancies: three full-term, one preterm, and one abortion. How would the nurse document this information on the patient chart?
G5 P3114
A client presents to the office for her obstetric history. She tells the nurse she has 4 children living at home. One child was born at 34 weeks, another child at 37 weeks, two were born consecutively at 38 and 39 weeks, and one was aborted. Record the client's obstetric record using the GTPAL format.
G5, T2, P2, A1, L4
The nurse is caring for a neonate whose mother received no medical care for either of her pregnancies. When assessing the neonate's status, which would indicate a potential A, B, and O incompatibility?
Hemolytic anemia
A nurse is providing care to a pregnant woman. To promote optimal outcomes, the nurse would engage in which activity? Select all that apply.
Individualized assessment Counseling Teaching
A pregnant woman who had stress incontinence during a previous pregnancy asks the nurse what could be done to manage this in her current pregnancy. What should the nurse recommend to the client?
Kegel exercises
A teenager arrives in the emergency department in active labor having no prenatal care. Upon examination in L & D, the nurse notices a cluster of pinpoint vesicles with a red base on her vulva which the teenager asks the nurse to not touch "her rash" because it hurts when touched. At this point, which intervention should the nurse perform next?
Report this finding to the health care provider immediately so he or she can plan the birth route.
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy?
Soft systolic murmur
A nurse is obtaining a health history and social profile from a newly pregnant patient and asks the patient about physical activity. The nurse specifically investigates if the patient goes hiking or camping. The nurse asks about these activities primarily for which reason?
To assess the patient's risk for Lyme disease
A woman has a positive pregnancy test and comes to the nurse with left lower quadrant pain. Bimanual examination reveals a tender mass. Which of the following is suspected?
Tubal pregnancy
A nurse is assessing a pregnant client. Which of the following would the nurse document as an abnormal finding in a pregnancy?
Visual changes
The nurse is conducting a prenatal class for a group of primigravida clients. Which instruction will the nurse prioritize when teaching about breast care?
Wash the nipples with clean water only
A nurse at the health care facility assesses a client in the 20th week of gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?
at the level of the umbilicus
A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location?
at the umbilicus
A pregnant client at 26 weeks' gestation has arrived for a routine prenatal visit. Which assessments should the nurse prioritize? Select all that apply.
blood pressure weight urine testing blood glucose level
During a routine prenatal visit, a client at 36 weeks' gestation states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. The nurse would develop a plan of care identifying interventions to promote which area as the priority?
gas exchange
A pregnant client tells the nurse that she has a 2-year-old child at home who was born at 38 weeks; she had a miscarriage at 9 weeks; and she gave birth to a set of twins at 34 weeks. Which documentation would be appropriate for the nurse?
gravida 4, para 2
A nurse is taking a history during a client's first prenatal visit. Which assessment finding would alert the nurse to the need for further assessment?
history of diabetes for 4 years
The nurse is providing care for a pregnant client who has been given the necessary requisitions for laboratory work by the primary care provider. The client notices that the lab tests include testing for HIV and other sexually transmitted infections, and expresses alarm, stating, "I don't understand why the doctor would suspect that I've got these diseases." What is the nurse's most therapeutic statement?
"Every pregnant client is tested for these diseases; it doesn't necessarily suggest that the doctor suspects that you have them."
The nurse is assessing a client's risk for sexually transmitted infections. Which statement by the client would be cause for concern?
"I am unsure who the father of the baby is. I will be raising it alone."
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year-old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:
4 1 1 1 3.
A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every:
4 weeks.
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure?
Amniocentesis
The nurse is assigned to clients who are having the following procedures: <br />Amniocentesis<br />Fetal nonstress test<br />Chorionic villus sampling<br />Percutaneous umbilical blood sampling<br />Doppler assessment of fetal heart rate<br />For which clients will the nurse ensure that the informed consent is on the chart?
Amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling
A client at 16 weeks' gestation is scheduled for prenatal testing. Which of the following would the nurse anticipate as the most likely screening test for congenital anomalies based on the current age of this pregnancy?
Amniocentesis.
A nurse is assessing a client who has come to the office to find out if she is pregnant after a home pregnancy test was positive. The nurse will record the client's last menstrual period in which component of her medical record?
Chief concern/complaint
As part of the assessment of a client's health history during the first prenatal visit, the nurse is having the client complete a 24-hour recall to establish what and how much the woman is eating. In which section of the health history should the nurse record this information?
Day history/social profile
The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is:
December 30
A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history?
G3 P0020
A client has been confirmed to be pregnant. She gives a history of two previous full-term normal pregnancies. How will the nurse classify the client's pregnancy history?
G3, P2
A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history?
G3, T0, P1, A1, L1
The nurse is assessing a woman who is pregnant for the first time. Which of the following terms applies to this client?
Primigravida
The nurse is caring for a client with a G=5, T=0, P=3, A=1, L=3 obstetric history. The nurse is most correct to state which interpretation?
The client has had difficulty reaching full term.
A nurse in an obstetric clinic is preparing the staff for a prenatal appointment with an incarcerated pregnant woman. What does the nurse explain is the main difference when an incarcerated client comes to the clinic?
There will be correction officers with the woman throughout her appointment.
A pregnant woman has come to the clinic for her first prenatal visit. The nurse informs the woman that the physician will do a pelvic examination at this time and that she should go empty her bladder. What is the primary reason the nurse instructs the patient to empty her bladder?
Urinating now will allow easier identification of organs.
The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting?
Watch it and report if heavy increase in bleeding.
An adolescent who is 8 weeks' pregnant is at her first perinatal visit. During the health history interview, the nurse asks the client, "Are you afraid of anyone?" What is the nurse assessing with this question?
intimate partner violence
A nursing student correctly identifies which action to be the best way to prevent complications of pregnancy?
receiving prenatal care
