NCLEX QUESTIONS 2
a primigravid client at 15 weeks gestation has received teaching about concerning signs and symptoms to report following amniocentesis. which statement indicates that the client needs further teaching? a.)"I need to call if I start to leak fluid from my vagina" b.) "If I start bleeding, I will need to call back" c.)"If my baby does not move, I need to call my health care provider" d.)"If I start running a fever, I should let the office know"
at 15 weeks gestation, a primipara will not feel the baby moving. quickening typically occurs between 18 and 20 weeks gestation for a primipara and between 16 and 18 gestation for a multipara. leaking fluid from the vagina should not occur until labor begins and may indicate a rupture of the membranes. bleeding an a fever are complications that warrant further evaluation and should be reported at any time during the pregnancy
The nurse is teach a new prenatal client about her iron deficiency anemia during pregnancy. which statement indicates that the client needs further instruction about her anemia? a.) "I will need to take iron supplements now" b.)"I may have anemia because my family is of Asian decent" c.) "I am considered anemic if my hemoglobin is below 11g/dL (110 g/L)" d.) "the anemia increases the workload on my heart"
iron deficiency anemia is caused by insufficient iron stores in the body, poor iron content in the diet of the pregnant woman or both. other thalassemias and sickle cell anemia, rather than iron deficiency anemias can associate with ethnicity but occur primarily in clients of African or Mediterranean origin. because red blood cells increase by about 50% during pregnancy many clients will need to take supplement to avoid deficiency. a pregnant client is considered anemic when the hemoglobin is below 11mg/dL. in most types of anemia , the heart must pump more often and harder to deliver oxygen to cells
using Nagele's rule for a client whose last normal menstrual period began on May 10th, the nurse determines that the client's estimated date of birth is what date? a.)January 13 b.) January 17 c.)February 13 d.)February 17
when using Nagels rule to determine the estimated date of birth the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days. this means the client's estimated date is Feb. 17
after instructing a female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states which hormone is evaluated by this test? a.)prolactin b.)follicle-stimulating hormone c.)luteinizing hormone d.)human chorionic gonadotropin (hCG)
the hormone analyzed in most pregnancy tests is hCG. in the pregnancy woman trace amounts of hCG appear in the serum as early as 24 to 48 hours after implantation owing to the trophoblast production of this hormone. prolactin, follicle-stimulating hormone, and luteinizing hormone are not used to detect pregnancy. prolactin is the hormone secreted by the pituitary gland to prepare the breasts for lactation. follicle-stimulating hormone is involved in follicle maturation during the menstrual cycle. luteinizing hormone is responsible for stimulating ovulation.
A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. The nurse determines that the couple needs further instruction when they identify which factor as a cause of male infertility? a.) seminal fluid with an alkaline pH b.) frequent exposure to heat sources c.) abnormal hormonal stimulation d.) immunological factors
The couple needs further instructions when they identify that one cause of male infertility is decreased sperm count due to seminal fluid that has an alkaline pH. A slightly alkaline pH is necessary to protect the sperm from the acidic secretions of the vagina and is a normal finding. an alkaline pH is not associated with decreased sperm count. however seminal fluid that is abnormal in amount, consistency, or chemical composition suggest obstruction, inflammation, or infection, which can decrease sperm production. the typical number of sperm produced during ejaculation is 400 million. frequent exposure to heat sources, like saunas and hot tubs can decrease sperm production, as can abnormal hormonal stimulation. Immunological factors produced by the man against his own sperm (autoantibodies) or by the woman can cause the sperm to clump or be unable to penetrate the ovum, thus contributing to infertility
a primigravid client at 10 weeks gestation questions the nurse about the need for an ultrasound. she states, "I feel fine, so why should I have the test?" the nurse should incorporate which statements as the underlying reason for performing the ultra sound now? select all that apply a.)"the test helps us view the gross anatomy of the fetus" b.)"we need to determine gestational age" c.)"the test will determine if the fetus is viable" d.)"we must determine the fetal position" e.)"we must determine that there is a sufficient nutrient supply for the fetus"
While initially continuing to attempt to find the fetal heartbeat the nurse can ask the client if the baby has been moving. this will give a quick idea of status. the next step would be to obtain different equipment and attempt to find the fetal heartbeat again . a simple statement of fact that the nurse cannot find the heartbeat is taking strep to rule out equipment error is appropriate. calling the HCP would be the last step after it is determined that the baby does not have a heartbeat
during a visit to the prenatal clinic a pregnant client at 32 weeks gestation has heartburn. the client needs further instruction when she says she must do what to manage heartburn? a.) avoid highly seasoned foods b.)avoid lying down right after meals c.)eat small frequent meals d.)consume liquids only between meals
consuming liquids between meals rather than at the same time as eating is an excellent strategy to deter nausea and vomiting in pregnancy but does not relieve heartburn. during the third trimester, progesterone causes relation of the sphincter and pressure of the fetus against the stomach increases potential of heartburn. avoiding highly seasoned foods, remaining in an upright position after eating, and eating small frequent meals are strategies to prevent heartburn
an antenatal primigravid client has just been informed that she is carrying twins. the plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. the nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which complication? a.) preterm labor b.) twin- to-twin transfusion c.)anemia d.)group B streptococcus
group B streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins. the multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation. the normal uterus is only able to distend to a certain point and when the point is reached, labor may be initiated. twin-to-twin transfusion drains blood from one twin to the second and is a problem and may occur with multiple gestations. the donor twin may become growth restricted and can oligohydramnios, while the recipient twin may become polycythemic with polyhydramnios and develop heart failure. anemia is a common problem with multiple gestation clients. the mother is commonly unable to consume enough protein, calcium, and iron to supply her needs and those of the fetuses. a maternal hemoglobin level below 11mg/dL (110g/L) is considered anemic
when measuring the fundal height of a primigravid client at 20 weeks gestation, the nurse will locate the fundal height at which point? a.)halfway between the client's symphysis pubis and umbilicus b.)at about the level of the client's umbilicus c.)between the client's umbilicus and xiphoid process d.) near the client's xiphoid process and compressing the diaphragm
measurement of the client's fundal height is a gross estimate of fetal gestational age. at 20 weeks gestation, the fundal height should be at about the level of the client's umbilicus. the fundus typically is over the symphysis pubis at 12 weeks. a fundal height measurement between these two areas would suggest a fetus with gestational age between 12 and 20 weeks. the fundal height increases approximately 1cm/week after 20 weeks gestation. the fundus typically reaches the xiphoid process at approximately 36 week's gestation. a fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. the fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. additionally, pressure on the diaphragm occurs late in pregnancy. therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.
a 20 year old married client with a positive pregnancy test states, "is it really true? I can't believe I am going to have a baby!" Which response by the nurse would be MOST appropriate at this time? a.)"would you like some booklets on the pregnancy experience?" b.)"yes, it is true. How does that make you feel?" c.) "You should be delighted that you are pregnant" d.) "what concerns you about this pregnancy?"
this client is expressing a feeling of surprise about having a baby. therefore the nurse's best response would be to confirm the pregnancy, which is something that the client already suspects, and then ascertain how the client is feeling now that the suspicion is confirmed. studies have shown that a common reaction to pregnancy is summarized as ambivalence or "someday, but not now." such feelings are normal and are experience by many women early in pregnancy. offering a pamphlet on pregnancy does not respond to the client's feelings. telling the client that she should be delighted ignores, rather than addresses, the client's feelings. also, doing so imposes the nurse's opinion on the client. ambivalence is a common reaction to pregnancy. telling the client that she should be delighted may lead to feelings of guilt. asking about the client's concerns is premature until the nurse determines the client's overall feelings about the pregnancy.
a newly diagnosed pregnant client tells the nurse, "If I am going to have all of these discomforts, I am not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which perception? a.) fear or pregnancy outcome b.)rejection of the pregnancy c.)normal ambivalence d.)limited self-care abilities
women normally experience ambivalence when pregnancy is confirmed, even if the pregnancy was planned. although the client's culture may play a role in openly accepting the pregnancy, most new mothers who have been ambivalence initially accept the realize by the end of the first trimester. ambivalence also may be expressed throughout the pregnancy, this is believed to be related to the amount of physical discomfort. the nurse should become concerned and perhaps contact a social worker if the client expresses ambivalence in the third trimester. the client's statement reflects ambivalence, not fear. there is no evidence to suggest of imply that the client is rejecting the fetus. the client's statement reflects ambivalence about the pregnancy, not her ability to care for herself
a 30 year old mutligravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. she is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation of her face and abdomen. these assessment findings reflect this women is experiencing a cluster of which signs? a.)positive b.) probable c.) presumptive d.)diagnostic
The plan of care should reflect that this woman is experiencing probable signs of pregnancy. she may be pregnant but the signs and symptoms may have another etiology. an enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease process as well as pregnancy. changes in the pigmentation of the face may also be caused by oral contraceptive use. positive signs of pregnancy are considered diagnostic and include evident fetal heart beat, fetal movement felt but a trained examiner and visualization of the fetus with ultrasound confirmation. presumptive signs are subjective and can have another etiology. these signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. the word "diagnostic" is not used to describe the condition pregnancy.
examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. the client denies any perineal itching or burning. the nurse interprets these findings as a response related to which factor? a.) a decrease in vaginal glycogen stores b.) development of a sexually transmitted disease c.) prevention of expulsion of the cervical mucus plug d.) control of the growth of pathological bacteria
an increase is clear, highly acidic finding during pregnancy that aids in controlling the growth of pathologic bacteria. vaginal secretions increase because of the influence of estrogen secretion and increased vaginal and cervical vascularity. the highly acidic nature of the vaginal secretions is caused by the action of Lactobacillus acidophilus, which increases the lactic acid content of the secretions. the increased acidity helps to make the vagina resistant to bacterial growth. during pregnancy, estrogen secretion fosters a glycogen-rich environment. unfortunately, this glycogen-rich acidic environment fosters the development of yeast (candida albicans)_ infections , manifested by itching, burning, and a cheese-like vaginal discharge. if the client had a sexually transmitted infection, most likely she would have addition symptoms such as, lesions in the genital area or changes in color, consistency, or odor of the vaginal secretions. an increase in vaginal secretions does not help prevent expulsion of the mucus plug. the mucus plug is held in place by the cervix until the cervix becomes ripe.
a client approximately 11 weeks pregnant and her husband are seen in the antepartal clinic. the client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. the nurse interprets these findings as suggesting that the client's husband is experiencing which complication? a.)ptyalism b.)mittelschmerz c.) Couvade syndrome d.) pica
couvade syndrome refers to the situation in which the expectant father experiences some of the discomforts of pregnancy along with the pregnant woman as a means of identifying with the pregnancy. ptyalism is the term for excessive salivation . mittelschmerz is the lower abdominal discomfort felt by some women during ovulation. pica refers to an oral craving for substances such as clay or starch that some pregnant clients experience.
Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which information about a change the client can anticipate in the first trimester a.)differentiating the self from the fetus b.)enjoying the role of nurturer c.)preparing for the reality of parenthood d.)experiencing ambivalence about pregnancy
many women in their first trimester feel ambivalent about being pregnant because of the significant life changes that occur. ambivalence can be expressed as a list of positive and negative consequences of having a child consideration of financial, career, or social implications. during the second trimester the infant becomes a separate individual to the mother. the mother will begin to enjoy the role of nurturer postpartum. during the third trimester the mother beings to prepare for parenthood and all of the tasks it includes.
a primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. which statement would be the nurse's best response? a.)"the effects of alcohol on a fetus during pregnancy are unknown" b.)"you should limit your consumption to beer and wine" c.)"you should abstain from drinking alcoholic beverages" d.)"you may have 1 drink of 2 oz alcohol per day
maternal alcohol use may result in fetal alcohol syndrome, marked by mild-to-moderate mental retardation, physical growth retardation, central nervous system disorders, and feeing difficulties. because there is no definitive answer as to how much alcohol can be safely consumed by a pregnant woman, it is recommended that pregnant clients be taught to abstain from drinking alcohol during pregnancy. smoking and other medications also may affect the fetus
The nurse is caring for a client who is 12 weeks pregnant and speaks spanish only. Which interventions should the nurse include in the plan of care at the client's initial visit? Select all that apply a.)provide brochures in the client's native language b.)refer the client to a high-risk clinic c.) discuss differences with the dominant culture d.)arrange for an interpreter for her appts e,)discuss contraception and options f.)review nutritional preferences
providing culturally sensitive care includes providing printed material in the client's native language. there is nothing to indicate that this client has a high-risk pregnancy. discussing cultural differences is not a priority or important at the first visit. clients need to have an interpreter for each prenatal visit to translate and interpret questions. contraceptive options are not a priority for the first prenatal visit. reviewing dietary intake an discussing nutrition are an important component of early prenatal care
after instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client makes which statement? a.)"a total weight gain of approx. 20lbs (9kg) is recommended" b.)"a weight gain of 6.6lbs (3kg) in the second and third trimesters is considered normal" c.)"a weight gain of about 12lbs (5.5kg) every trimester is recommended" d.)"although it varies, a gain of 25 to 35lbs (11.4 to 14.5kg) is about average"
the national academy of sciences institution of medicine and health canada recommend that pregnant women gain 25 to 35lbs during pregnancy. the pattern of weight gain is as important as the total amount of weight gained. underweight women and women carrying twins should have a greater weight gain. typically, women should gain 3.5lb during the first trimester and then 1lb/week during the remainder of the pregnancy (24 weeks) for a total of about 27 to 28lbs. a weight gain of only 6.6lbs in the second and third trimester is not normal because the client should be gaining about 1lb/week or 12lbs during the second and third trimesters. gaining 12lbs during each trimester would total 36lbs which is slightly more than the recommended weight gain. in addition, nausea and vomiting during the first trimester can contribute to a lack of appetite and smaller weight gain during this trimester
after instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she say that which hormone is produced by the placenta? a.)estrogen b.)progesterone c.)human chorionic gonadotropin (hCG) d.)testosterone
the placenta does not produce testosterone. human placenta lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. the hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. estrogen results in uterine and breast enlargement. progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. the placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi
When preparing a 20 year old client for a serum pregnancy test the nurse should include what information? a.)the test has a high degree of accuracy within 1 week after ovulation b.) the test is identical in nature to an over the counter home pregnancy c.)a positive result is considered a presumptive sign of pregnancy d.)a urine sample is needed to obtain quicker results
the serum pregnancy test measures hCG in blood plasma and is highly accurate within 1 week after ovulation. the test is performed in a laboratory. OTC pregnancy tests are preformed on urine and typically require higher levels of hCG to become positive. a positive pregnancy test is considered a probably sign of pregnancy. certain condition other than pregnancy such as choriocarcinoma can cause increased hCG levels.
a primigravida at 8 weeks gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. the nurse informs the client that she will need to wait until she is at 15 weeks gestation for the amniocentesis. which is the MOST appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks gestation? a.)fetal development needs to be complete before testing b.)the volume of amniotic fluid needed for testing will be available by 15 weeks c.)cells indication hemophilia A are not produced until 15 weeks gestation d.) performing an amniocentesis prior to 15 weeks gestation carries a greater infection rate
the volume of fluid needed for amniocentesis is 15mls, and this is usually available at 15 weeks gestation. fetal development continues throughout the prenatal period. cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks gestation. amniocentesis carries a slight risk of infection regardless of when the procedure is performed.
