NCLEX Maternity Antepartum
Concern about her appearance
A 23-year-old client 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. Breast tenderness 2. Early morning nausea 3. No menstruation for the last 8 weeks
A 26-year-old woman comes to the clinic and asks for a pregnancy test because she thinks she might be pregnant. The nurse assesses for which presumptive signs of pregnancy? Select all that apply.
A 3-hour glucose tolerance test
A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription should the nurse anticipate for the client?
A 3-hour glucose tolerance test
A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose level is elevated. Which prescription should the nurse anticipate for the mother?
Eighth
A client asks the 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. Bypassing the fetal lungs to circulate oxygen rich blood 2. Using the fetus's beating heart to pump blood in the circulatory system 3. Carrying more oxygen on fetal hemoglobin than maternal hemoglobin 4. Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output
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 means? Select all that apply.
"Tell me about your concerns."
A client at 32 weeks of gestation 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?
Human chorionic gonadotropin (hCG)
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 in the urine?
Amniocentesis for fetal surfactant level
A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the health care provider to prescribe?
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
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 reinforces a list of instructions for the client regarding management of care. Which instructions would the nurse place on the list? Select all that apply.
Trace amount of protein
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?
"You feel you are having difficulty fulfilling your role as a wife."
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 statement by the nurse indicates an understanding of the problem?
Wear a perineal pad to the play.
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 measure is appropriate to suggest to the client?
1. Clear fluid 2. White flecks in the amniotic fluid 5. Presence of glucose and protein in the amniotic fluid
A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.
1. Clear fluid 2. White flecks in the amniotic fluid 3. Presence of glucose and protein in the amniotic fluid
A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.
"I should avoid stressful situations."
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 she understands her needs?
Inevitable
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?
Breast changes
A client presents at her health care provider's office 10 weeks pregnant with her first pregnancy. Which is a presumptive sign of pregnancy that the client might be expected to have?
Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures
A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?
Fetal demise
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 4, para 0, abortion 3. 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?
Eat crackers before arising.
A client who is 8 weeks pregnant calls the clinic and speaks to the nurse about complaints of nausea and vomiting every morning. Which action should the nurse suggest to promote relief?
"I should choose underwear with a cotton panel liner."
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?
"The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."
A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?
Administration of immune globulin and vaccine in the infant soon after birth
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?
Calcium gluconate
A licensed practical nurse (LPN) is assisting in the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop the contractions. The LPN checks to see that which is available on the unit as an antidote to magnesium sulfate?
"I shouldn't have eaten so many sweets before I became pregnant."
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?
A negative test
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. Which interpretation should the nurse make of these results?
"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."
A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement should the nurse provide to the client?
18
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 which week of gestation?
1. Edema 2. Proteinuria 3. Thrombocytopenia
A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.
Week 28
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?
Connects the umbilical vein to the inferior vena cava
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 which about the ductus venosus?
"It increases during pregnancy to stimulate basal metabolic rate."
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?
To avoid exercise because of the negative effects on insulin production
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?
Avoid exposure to litter boxes used by cats.
A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?
"It is best to rest on my right side."
A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client would indicate the need for further teaching?
"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."
A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?
Between 16 and 20 weeks' 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 should be noted at which time interval?
16 and 20 weeks' 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 which weeks of gestation?
Longest period of fetal development
A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?
January 12
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, which would be the estimated date of delivery (EDD)?
12 to 16
A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?
The client is blaming herself.
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?
The breast changes are a result of the secretion of estrogen and progesterone.
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 what information?
Instruct the client that these are common and may occur throughout the pregnancy.
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 nursing action should be appropriate?
Instruct the client that these are common and may occur throughout the pregnancy.
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 nursing action should the nurse take?
Tell the client that these are common and they may occur throughout the pregnancy.
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?
Consume dry crackers before getting out of bed.
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?
Hemoglobin 9.1 g/dL
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 laboratory result indicates a physiological consequence of a result of this practice?
"I am so glad that I can breast-feed my baby after she has been vaccinated."
A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?
"The better control of your blood glucose means less effects; let's review your plan of care."
A pregnant client who has gestational diabetes mellitus 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?
"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."
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?
"You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."
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?
Adding 1 tablespoon of mineral oil to a bowl of cereal daily
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?
"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."
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 should the nurse make to help reduce the maternal fears that the newborn will be born with an infection?
Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.
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 reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?
"The preembryonic period is the first 2 weeks of fetal development following conception."
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. How does the nurse describe the preembryonic period for the client?
Placenta previa
A pregnant woman who is at 38 weeks gestation 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, what does the nurse determine the client may be experiencing?
Fear about the safety of the fetus
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 client problem does the nurse identify as important at this time?
Fetal heart rate of 180 beats per minute
A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing?
"This is an emergency; you should come to the clinic within the hour."
A woman at 20 weeks of gestation calls the health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?
1. Avoid greasy foods. 2. Eat 5 to 6 small meals each day. 3. Do not drink fluids with meals.
A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply.
"Can you tell me more about what you are eating?"
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, which is the best response by the nurse?
Initiating severe hemorrhage
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?
150 beats per minute
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 heart rate is noted?
"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."
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 makes which statement?
Blood pressure changes and the presence of protein in the urine
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." Which would the nurse check further?
"I am eating fresh fruits and vegetables for snacks and for dessert each day."
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 the goal has been achieved when the client makes which statement?
Reports of fatigue
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?
T lymphocyte levels
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 laboratory study would further support the presence of HIV?
To identify appropriate fetal development
During the antenatal period of a client diagnosed with the human immunodeficiency virus (HIV), the nurse result of her rubella screening is positive. routinely and discusses the findings. Which is the primary purpose of this action?
Weight compared to last visit is a loss of 2.3 pounds
During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding indicates a serious nutritional disorder of pregnancy?
Establish a therapeutic relationship between the nurse and pregnant client.
In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?
July 27, 2017
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, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?
Provides an exchange of nutrients and waste products between the mother and the fetus
The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?
"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."
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 makes which statement?
Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.
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 should recommend which measure to help relieve both discomforts?
Providing the mother with pamphlets and booklets to read about the pregnancy
The 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?
An adolescent with multiple heterosexual contacts
The 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?
Reduce excessive maternal stress and fatigue.
The nurse assists a pregnant client with cardiac disease in identifying 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 accomplish which?
Petechiae, oozing from injection sites, and hematuria
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 which is observed?
Vaginal spotting twice since the last prenatal visit
The 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?
"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."
The nurse employed in a health care provider's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral?
Minimize the potential for developing infections.
The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?
"The iron is needed for the red blood cells."
The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which would indicate successful learning?
1. Peanut butter 2. Whole grain bread 4. Omelet with cheese
The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.
1. Pulse 2. Blood volume 3. Cardiac output 4. Red blood cell mass
The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.
Beans
The 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 which food item?
"I need to gain only 10 pounds so that my baby will be small like I am."
The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?
Assists in identifying infections that may need to be treated
The 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. Which is the primary expected outcome for this intervention?
Document the temperature.
The 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?
Fundal height, 38 cm
The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the health care provider?
Minimizing the client's exposure to external stimuli
The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?
1 Vaginal bleeding 2. Excessive vomiting 3. No fetal heart activity 4. Larger than normal fetus size for gestational age 5. Elevated levels of human chorionic gonadotropin (HCG)
The 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 findings are associated with this diagnosis? Select all that apply.
1. Vaginal bleeding 2. Excessive vomiting 3. No fetal heart activity 4. Larger than normal fetus size for gestational age 5. Elevated levels of human chorionic gonadotropin (HCG)
The 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 findings are associated with this diagnosis? Select all that apply.
Dehydration
The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority?
Place a wedge pillow under the client's right side.
The 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. Which action should the nurse perform first?
Cause hemorrhage.
The nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could do which?
Prolactin
The nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that which hormone primarily stimulates the secretion of milk?
How to check for signs of hypoglycemia and the required treatment
The nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?
The client will be able to identify measures to prevent infection.
The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?
Second
The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?
The client exhibits no signs of fetal distress.
The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?
Providing the mother with pamphlets and booklets to read about the pregnancy
The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would be least likely to assist in meeting her emotional needs?
Travel precautions and use of shoulder seat belts
The 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 topic should be a part of the teaching plan for this class?
Placing external fetal monitors so that each fetal heart rate is monitored separately
The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?
"I should expect that my urine output will decrease."
The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia?
Acute anxiety and the need for support
The 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 which situation?
Deep tendon reflexes
The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which should the nurse specifically monitor?
"Breast-feeding is contraindicated."
The 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?
Potential for infection
The nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?
Maternal hypertension
The 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 risk factor?
A urinary tract infection
The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which findings would place the client at risk for preterm labor?
She has a history of chronic hypertension.
The 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?
Gravida II, para I
The nurse is collecting data from 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 should document which gravida and para status on this client?
G = 2, T = 1, P = 0, A = 0, L = 1
The nurse is collecting data from 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 should document the GTPAL for this client as which?
Maternal anemia
The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complication is associated with a twin pregnancy?
1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
Signs of fetal distress
The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority?
Are where fertilization occurs
The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?
28 cm
The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?
Vulva
The 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 area, knowing that venous congestion is most commonly noted where?
A history of intravenous (IV) drug use in the past year
The nurse is collecting data from a prenatal client. The nurse determines that which places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?
1. Ballottement 2. Fetal movements felt by examiner
The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.
Hypertension
The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to a potential problem specifically related to the twin pregnancy?
1. Oliguria 2. Proteinuria 3+ 3. Blood pressure 168/116 mm Hg
The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms would be noted in severe preeclampsia? Select all that apply.
In a sitting position
The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. Which position should the nurse place the client in?
Document the assessment.
The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take?
Prolactin
The nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that which hormone stimulates the secretion of milk?
Two umbilical arteries and one umbilical vein
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which?
1. Urinalysis 2. Rubella titer 3. Complete blood count
The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant and shares that which tests are expected to be conducted during the first trimester? Select all that apply.
The client complains of a headache and blurred vision.
The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?
"I don't like my face anymore. I always look like I have been crying."
The 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 client statement indicates a need for further investigation?
Weight and height
The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data?
Pregnancy greatly increases the risk of malnourishment for the mother.
The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?
Fresh spinach
The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?
Proteinuria 2. Hypertension 3. Increased pulse rate
The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.
Chamomile should not be used by pregnant women and persons with asthma.
The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking and the client tells the nurse that she has been taking the herb chamomile. The nurse refers to an herbal reference book and discovers which fact about chamomile?
The client will feel some pressure when the vaginal probe is moved.
The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?
1. Curtail exercise. 2. Measure your blood pressure daily. 3. Rest frequently by lying on your side. 4. Call the health care provider if you develop dizziness.
The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply.
Pulse
The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first?
The nutritional status of the mother significantly influences fetal growth and development.
The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?
1. Facial edema 2. Rapid weight gain 3. Visual disturbances 4. Generalized edema
The 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. Which warning signs would the nurse place on the list? Select all that apply.
The feelings of guilt that is often associated with grief
The 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 psychosocial issue?
Avoid further stress on the maternal immune system.
The 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 accomplish which goal?
To avoid further stress on the maternal immune system
The nurse is providing information about health care to a pregnant client who is positive for human immunodeficiency virus (HIV). What is the primary reason to avoid alcohol and cigarettes during pregnancy and to get adequate rest?
Nuts and green, leafy vegetables
The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?
A cesarean section will be necessary if vaginal lesions are present at the time of labor.
The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?
Flat and unfavorable for a vaginal birth
The 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 which?
1. Narrow wedge shape 2. Unfavorable for a vaginal birth
The 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. Which terms apply to an android pelvis? Select all that apply.
Dried fruits
The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse should instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?
Palpate for uterine contractions at the same time as the client.
The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use?
Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.
The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?
Irregular, painless contractions
The nurse is reinforcing instructions to 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 occurs?
"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
The nurse is reinforcing instructions to 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?
Perform Kegel exercises in 10 repetitions, three times per day.
The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions?
Drink decaffeinated coffee and tea.
The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?
Green, leafy vegetables
The nurse is reinforcing 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 food item in the diet?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
The nurse is reinforcing teaching to 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 purpose of estrogen?
Reducing maternal stress and fatigue
The nurse is reinforcing the positive effects of breathing and relaxation techniques to a pregnant, cardiac client who has an 18-month-old child. Which primary outcome is the purpose for these interventions?
Midway between the symphysis pubis and the umbilicus
The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. The nurse should expect documentation that the fundus of the uterus is noted at which area?
Midway between the symphysis pubis and the umbilicus
The nurse is reviewing the health care record of a pregnant client at 16 weeks' gestation. The nurse should expect documentation that the fundus of the uterus is noted at which area?
Just above the symphysis pubis
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 area?
Increased blood volume of the mother during pregnancy
The 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?
Estrogen
The 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 which hormone responsible for the development of this sign?
Estrogen
The 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?
Estrogen
The 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 which hormone is responsible for the development of this sign?
Strengthen the pelvic floor in preparation for delivery.
The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose?
Progesterone maintains the uterine lining for implantation.
The 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. According to the nurse, what is the purpose of progesterone?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
The 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 purpose of estrogen?
1. Increases blood flow to the uterine vessels 2. Stimulates development of the breast ducts 3. Causes vascular changes in the mucous membranes of the nose and mouth
The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.
Maternal hypertension
The 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?
Palpate for uterine contractions at the same time as the client.
The nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as an effective teaching method?
A normal finding
The nurse notes that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which is the explanation for this increase?
The most common presentation
The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. The nurse understands that this characterizes which type of presentation?
"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."
The nurse shares with a pregnant client that the result of her rubella screening is positive. Which 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. "Lie on your left side for an hour and try to drink some fluids." 2. "It is important that you urinate frequently to keep your bladder empty." 3. "Palpate for contractions and call back if there are more than four contractions in the next hour." 4. "Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"
The 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 responses by the nurse indicate a understanding of the implications of the client's symptoms? Select all that apply.
The most favorable for labor and birth
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 which is a characteristic of this type of pelvis?
In the fallopian tube
The 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 identified by the student indicates an understanding of this process?
"It is the fetal movement that is felt by the mother."
The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?
Pelvis
The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that supports and protects the internal reproductive organs. The student correctly responds by identifying which structure?
A diet that is high in fluids and fiber to decrease constipation
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 should consult with the dietitian to ensure which dietary measure?
Subcutaneous administration of heparin sodium 5000 units daily
The 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 medication is prescribed?
Dorsiflex the client's foot while extending the knee.
The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?
The client will not develop an opportunistic infection during the remainder of pregnancy.
When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?
A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago
When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors would the nurse consider significant?
"Do you have any cats as house pets, and if so, do you ever come in contact with their soiled kitty litter?"
When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?
Expression of hope for a positive outcome
When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?
Cesarean section birth
Which history would place a maternity client at risk for uterine rupture?
"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."
Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?
Compression of the vena cava
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 which?